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Psychological
Disorders
The Courage to Wake Up Every Morning
B
ill Garrett was a freshman scholarship recipient at Johns Hopkins University when he began to hear strange voices
inside his head. Those voices told him profoundly disturbing things: that he was stupid and fat, that soap and shampoo were toxic, that his father had poisoned the family dog, and that his grandmother was putting human body parts
in his food. Bill withdrew into this terrifying inner world. Eventually, he was diagnosed with schizophrenia, a disorder
characterized by disturbed thought. Failing in his classes, this previously excellent student (and track and lacrosse
star) was forced to return home.
Bill’s mother understood her son’s experience when she found herself at a support group for families of individuals with
schizophrenia. At one point, surrounded by 10 people all speaking to her at once, she was overwhelmed by the confusing
cacophony. Afterward she told her son, “You have to be the most courageous person. You wake up every morning”
(M. Park, 2009). Bill had told her that sleep was his only escape from the ceaseless terror of hearing those voices.
At home, Bill was constantly faced with evidence of his previous successes. Looking at his trophies and awards, he
said, “Mom, I was on top of the world. Now I’m in the gutter.” His mother, however, has encouraged him to think of
his disorder not as a sign of failure but as an opportunity to use the gifts he still possesses—symbolized by those
past accomplishments—to fight for the rights and well-being of individuals who, like him, find their lives turned
upside-down by psychological disorders.
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This chapter explores the meaning of the word abnormal as it relates to psychology. We
examine various theoretical approaches to understanding abnormal behavior and survey
the main psychological disorders. We delve into how stigma plays a role in the lives of
individuals struggling with psychological disorders, and we consider how even difficult,
troubled lives remain valuable and meaningful.
Defining and Explaining
1 Abnormal Behavior
abnormal
behavior
Behavior that is
deviant, maladaptive, or personally distressful
over a relatively
long period of
time.
What makes behavior “abnormal”? The American Psychiatric Association (2001, 2006,
2013) defines abnormal behavior in medical terms: a mental illness that affects or is manifested in a person’s brain and can affect the way the individual thinks, behaves, and
interacts with others. Abnormal behavior may also be defined by three criteria that distinguish it from normal behavior: Abnormal behavior is deviant, maladaptive, or personally
distressful over a relatively long period of time. Only one of these criteria needs to be
present for a behavior to be labeled “abnormal,” but typically two or all three are present.
E X PE R I E N C E I T !
Normal vs. Abnormal
Behavior
Three Criteria of Abnormal Behavior
Let’s take a close look at what each of the three characteristics of abnormal behavior entails:
■
Abnormal behavior is deviant. Abnormal behavior is certainly atypical or statistically
unusual. However, Alicia Keys, Hope Solo, and Mark Zuckerberg are atypical in many
of their behaviors, and yet we do not categorize them as abnormal. We do often consider
Accomplished individuals such as singer-songwriter Alicia Keys, champion soccer goalkeeper Hope Solo, and Facebook CEO Mark Zuckerberg are atypical
but not abnormal. However, when atypical behavior deviates from cultural norms. it often is considered abnormal.
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Context matters! If
the woman who washes her hands
three or four times an hour and
takes repeated showers works in
a sterile lab with toxic chemicals
or live viruses, her behavior
might be quite adaptive.
atypical behavior abnormal, though, when it deviates from what is
acceptable in a culture. A woman who washes her hands three or
four times an hour and takes seven showers a day is abnormal
because her behavior deviates from culturally acceptable norms.
Abnormal behavior is maladaptive. Maladaptive behavior interferes
with one’s ability to function effectively in the world. A man who
believes that he can endanger others through his breathing may go to
great lengths to isolate himself from people for what he believes is their
own good. His belief negatively affects his everyday functioning; thus, his
behavior is maladaptive. Behavior that presents a danger to the person or
those around him or her is also considered maladaptive (and abnormal).
Abnormal behavior is personally distressful over a long period of
time. The person engaging in the behavior finds it troubling. A
woman who secretly makes herself vomit after every meal may
never be seen by others as deviant (because they do not know
about it), but this pattern of behavior may cause her to feel intense
shame, guilt, and despair.
Which of these three
qualities—deviation from what is
acceptable, maladaptiveness, and
personal distress—do you think
is most important to calling
a behavior abnormal? Why?
Culture, Context, and the Meaning
of Abnormal Behavior
Because culture establishes the norms by which people evaluate their own and others’
behaviors, culture is at the core of what it means to be normal or abnormal (Agorastos,
Haasen, & Huber, 2012). In evaluating behavior as normal or abnormal, culture
matters in complex ways (Sue & others, 2013). Cultural norms provide guidance about how people should behave and what behavior is healthy or
unhealthy. Importantly, however, cultural norms can be mistaken. One only
has to watch an episode of Mad Men to recognize that at one time cigarette
smoking was not only judged to be an acceptable habit but also promoted as
a healthy way to relax. The point is, definitions of normal change as society
changes.
Significant, too, is the fact that cultural norms can be limiting, oppressive, and prejudicial (Potter, 2012). Individuals who fight to change the established social order sometimes face the possibility of being labeled deviant—and even mentally ill. In the late
nineteenth and early twentieth centuries, for instance, women in Britain who demonstrated for women’s right to vote were widely viewed to be mentally ill. When
a person’s or a group’s behavior challenges social expectations, we must open
our minds to the possibility that such actions are in fact an adaptive response
to injustice. People may justifiably challenge what everyone thinks is true and
may express ideas that seem strange. They should be able to make others
feel uncomfortable without being labeled abnormal.
Further, as individuals move from one culture to another, interpretations
and evaluations of their behavior must take into account the norms in their
Spend 15 to 20 minutes observing an
area with a large number of people,
culture of origin (Bourque & others, 2012; John & others, 2012). Hissuch as a mall, a cafeteria, or a
torically, people entering the United States from other countries were
stadium during a game. Identify and
examined at Ellis Island, and many were judged to be mentally impaired
make a list of behaviors you would
simply because of differences in their language and customs.
classify as abnormal. How does your
Cultural variation in what it means to be normal or abnormal makes it
list of behaviors compare with the
very difficult to compare different psychological disorders across different
definition of abnormal provided
cultures. Many of the diagnostic categories we trace in this chapter primarabove? What would you change in
ily
reflect Western (and often U.S.) notions of normality, and applying
the list if you were in a different
these
to other cultures can be misleading and even inappropriate (Agorastos,
setting, such as a church, a bar, or a
Haasen,
& Huber, 2012). Throughout this chapter, we will see how culture
library? What does this exercise tell
influences the experience of psychological disorders.
you about the meaning of abnormal?
Consider, for instance,
that a symptom of one of Sigmund
Freud ’s most famous patients,
Anna O., was that she was not
interested in getting married.
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Theoretical Approaches
to Psychological Disorders
What causes people to develop a psychological disorder, that is, to behave in deviant,
maladaptive, and personally distressful ways? Theorists have suggested various approaches
to this question.
THE BIOLOGICAL APPROACH
The biological approach attributes psychological disorders to organic, internal causes. This perspective primarily focuses on the brain,
genetic factors, and neurotransmitter functioning as the sources of abnormality.
The biological approach is evident in the medical model, which describes psychological disorders as medical diseases with a biological origin. From the perspective of
the medical model, abnormalities are called “mental illnesses,” the afflicted individuals
are “patients,” and they are treated by “doctors.”
medical model
The view that psychological
disorders are medical
diseases with a biological
origin.
THE PSYCHOLOGICAL APPROACH
The psychological approach emphasizes
the contributions of experiences, thoughts, emotions, and personality characteristics in
explaining psychological disorders. Psychologists might focus, for example, on the influence of childhood experiences, personality traits, learning experiences, or cognitions in
the development and course of psychological disorders.
THE SOCIOCULTURAL APPROACH
The sociocultural approach emphasizes
the social contexts in which a person lives, including gender, ethnicity, socioeconomic
status, family relationships, and culture. For instance, poverty is related to rates of psychological disorders (Jeon-Slaughter, 2012; Rosenthal & others, 2012).
The sociocultural perspective stresses the ways that cultures influence the understanding and treatment of psychological disorders. The frequency and intensity of psychological disorders vary and depend on social, economic, technological, and religious
aspects of cultures (Matsumoto & Juang, 2013). Some disorders are culture-related, such
as windigo, a disorder recognized by northern Algonquian Native American groups that
involves fear of being bewitched and turned into a cannibal.
Importantly, different cultures may interpret the same pattern of behaviors in very different ways. When psychologists look for evidence of the occurrence of a particular disorder in different cultures, they must keep in mind that behaviors associated with a
disorder might not be labeled as illness or dysfunction within a particular cultural context.
Cultures might have their own interpretations of these behaviors, so researchers must probe
whether locals ever observe these patterns of behavior, even if they are not considered
illness (Draguns & Tanaka-Matsumi, 2003). For example, in one study researchers interviewed a variety of individuals in Uganda to see whether dissociative disorders, including
dissociative identity disorder (which you might know as multiple personality disorder),
existed in that culture (Van Duijl, Cardeña, & de Jong, 2011). They found that while most
dissociative disorders were recognizable to Ugandans, the local healers consistently labeled
what Westerners consider dissociative identity disorder as a spirit possession.
THE BIOPSYCHOSOCIAL MODEL
Abnormal behavior can be influenced by
biological factors (such as genes), psychological factors (such as childhood experiences),
and sociocultural factors (such as gender). These factors can operate alone, but they often
act in combination with one another.
To appreciate how these factors work together, let’s back up for a moment. Consider
that not everyone with a genetic predisposition to schizophrenia develops the disorder.
Similarly, not everyone who experiences childhood neglect develops depression. Moreover, even women who live in cultures that strongly discriminate against them do not
always develop psychological disorders. Thus, to understand the development of psychological disorders, we must consider a variety of interacting factors from each of the
domains of experience.
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Sometimes this approach is called biopsychosocial. From the biopsychosocial perspective, none of the factors considered is necessarily viewed as more important than another;
rather, biological, psychological, and social factors are all significant ingredients in producing both normal and abnormal behavior. Furthermore, these ingredients may combine
in unique ways, so that one depressed person might differ from another in terms of the
key factors associated with the development of the disorder.
Classifying Abnormal Behavior
To understand, prevent, and treat abnormal behavior, psychiatrists and psychologists have
devised systems classifying those behaviors into specific psychological disorders. Classifying psychological disorders provides a common basis for communicating. If one
psychologist says that her client is experiencing depression, another psychologist understands that a particular pattern of abnormal behavior has led to this diagnosis. A classification system can also help clinicians predict how likely it is that a particular disorder
will occur, which individuals are most susceptible to it, how the disorder progresses, and
what the prognosis (or outcome) for treatment is (Birgegárd, Norring, & Clinton; Skodol,
2012a, 2012b).
Further, a classification system may benefit the person suffering from psychological
symptoms. Having a name for a problem can be a comfort and a signal that treatments
are available. On the other hand, officially naming a problem can also have serious
negative implications for the person because of the potential for creating stigma, a mark
of shame that may cause others to avoid or to act negatively toward an individual. Being
diagnosed with a psychological disorder can profoundly influence a person’s life because
of what the diagnosis means with respect to the person and his or her family and larger
social world. We discuss stigma further at the end of this chapter.
THE DSM CLASSIFICATION SYSTEM
In 1952, the American Psychiatric
Association (APA) published the first major classification of psychological disorders in
the United States, the Diagnostic and Statistical Manual of Mental Disorders. Its current
version, DSM-5, was approved in 2013. This edition of the DSM is the product of a
14-year revision process. DSM-5 differs in many ways from its predecessors. Throughout
the history of the DSM, the number of diagnosable disorders has increased dramatically.
For example, DSM-5 includes new diagnoses such as binge eating disorder and gambling
addiction.
The DSM is not the only diagnostic system. The World Health Organization devised the International Classification of Diseases and Related
Problems (ICD-10), which includes a chapter on mental and
behavioral disorders. One of the goals of the authors of
DSM-5 was to bring diagnoses closer to the ICD-10,
although the two manuals remain different in important ways.
CRITIQUES OF THE DSM
Even before it
was published, the DSM-5 was criticized on a number
of bases (British Psychological Society, 2011; Skodol,
2012a, 2012b; Spiegel & others, 2013; Widiger & Craigo,
2013). A central criticism that applies to all versions of the
DSM is that it treats psychological disorders as if they are
medical illnesses, taking an overly biological view of disorders
that may have their roots in social experience (Blashfield, 2014).
Even as research has shed light on the complex interaction of
genetic, neurobiological, cognitive, social, and environmental factors in
psychological disorders, the DSM-5 continues to reflect the medical
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DSM-5
The Diagnostic
and Statistical
Manual of Mental
Disorders, Fifth
Edition; the major classification
of psychological
disorders in the
United States.
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model (British Psychological Society, 2011), neglecting factors such as poverty, unemployment, and trauma. Another general criticism of the DSM is that it focuses strictly on problems. Critics argue that emphasizing strengths as well as weaknesses might help to
destigmatize psychological disorders. Identifying a person’s strengths can be an important
step toward maximizing his or her ability to contribute to society (Roten, 2007).
Other criticisms of the DSM-5 include these:
■
■
■
E X PE R I E N C E I T !
Attention Deficity
Hyperactivity Disorder
(ADHD)
It relies too much on social norms and subjective judgments.
Too many new categories of disorders have been added, some of which do not yet
have consistent research support and whose inclusion will lead to a significant increase
in the number of people being labeled as having a mental disorder.
Loosened standards for some existing diagnoses will add to the already very high
rates of these.
Figure 12.1 shows some of the changes that are part of the DSM’s newest formulation.
In thinking about the critiques of these revisions, you might be wondering what all the
fuss is about. One reason for these concerns is that U.S. insurance companies generally
will reimburse patients only for treatments for diagnoses that appear in the DSM-5.
Another reason for concern is that part of the medical model is the assumption that
disorders optimally are treated through medical means. Generally, that means prescribing
medications. With the loosening of diagnostic criteria, many more individuals might be
given powerful psychoactive drugs, perhaps unnecessarily. Thus, it is imperative that the
DSM gets it right, and many critics argue that it falls short in this high-stakes context
(Andrews, 2014; Blashfield, 2014; Paris, 2013; Watson & others, 2013).
Concerns are about overdiagnosis and the proliferation of psychoactive drugs are well
illustrated by the controversy surrounding attention-deficit/hyperactivity disorder (ADHD).
To read more, see Challenge Your Thinking.
Disorder
Change
Sources of Concern
Major
Depressive
Disorder
In the past, those experiencing
grief due to the loss of a loved one
generally have not been considered
depressed. This grief exclusion has
been dropped.
This change may result in those
experiencing normal grief to be
labeled with depression.
AttentionDeficit/
Hyperactivity
Disorder (ADHD)
Some of the diagnostic
requirements have been loosened,
and the age of diagnosis has been
changed.
Overdiagnosis of ADHD is already a
concern, as is the proliferation of
drugs used to treat the condition.
Autism
Spectrum
Disorder
The diagnosis of Asperger
syndrome, which was given to highfunctioning individuals with autistic
characteristics, has been dropped.
Those who were previously
diagnosed with Asperger’s may not
be diagnosed at all and may not
receive treatment.
Post-Traumatic
Stress
Disorder (PTSD)
Previously, a person had to have
experienced or witnessed a trauma.
Now, PTSD can be diagnosed even
for those who only hear about a
trauma.
The change may lead to a huge
increase in those with this disorder.
Disruptive Mood
Regulation
Disorder
This is a new diagnosis for children
with wild mood swings.
Adding diagnoses targeting children
is concerning.
Mild
Neurocognitive
Impairment
This new diagnosis is for adults
experiencing cognitive decline.
Many adults experience mild
cognitive decline with age, and this
diagnosis may pathologize normal
aging.
attention-deficit/hyperactivity
disorder (ADHD)
One of the most common
psychological disorders of
childhood, in which individuals show one or more of
the following: inattention,
hyperactivity, and impulsivity.
FIGURE 12.1 New Features of DSM-5 DSM-5 has dropped some diagnostic categories,
added others, and changed the criteria for still others.
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Challenge
YOUR THINKING
Does Everyone Have ADHD?
P
erhaps no diagnosis is more
controversial these days than
attention-deficit/hyperactivity
disorder (ADHD), in which individuals,
prior to the age of 7, show one or
more of the following symptoms:
inattention, hyperactivity, and impulsivity. Chances are you know someone who suffers from ADHD. You
might even have it yourself.
ADHD is one of the most common
psychological disorders of childhood,
with diagnoses skyrocketing in recent years. In 1988 just 500,000
cases of ADHD were diagnosed, but
by 2007, that number had jumped to
4 million per year (Bloom & Cohen, 2007). In 2010, 10.4 million
children were diagnosed with ADHD (Garfield & others, 2012).
Experts previously thought that most children “grow out of”
ADHD. However, based on evidence showing that as many as
70 percent of adolescents (Sibley & others, 2012) and 66 percent of adults (Asherson & others 2010) diagnosed as children
continue to experience ADHD symptoms, DSM-5 recognizes
ADHD in adults.
The sheer number of ADHD diagnoses has prompted speculation that psychiatrists, parents, and teachers are in fact labeling
normal childhood behavior as psychopathology (Morrow & others,
2012). One reason for concern about overdiagnosing ADHD is
that the form of treatment in well over 80 percent of cases is psychoactive drugs, including stimulants such as Ritalin and Adderall
(Garfield & others, 2012). Animal research has shown that in the
absence of ADHD, exposure to such stimulants can predispose
individuals to later addiction problems (Leo, 2005). Those who
question the diagnosis of ADHD in children find it equally problematic in adults (Marcus, Norris, & Coccaro, 2012). These scholars
argue that the spread of ADHD is primarily a function of overpathologizing normal behavior, confusing ADHD for other disorders, and aggressive marketing by pharmaceutical companies
(Moncrieff & Timimi, 2010).
A recent study sheds some light on the controversy. Child
psychologists, psychiatrists, and social workers were sent
vignettes of cases of children in which symptoms were described
(Brüchmiller, Margraf, & Schneider, 2012), and were asked to
diagnose the children. Some of the descriptions fit the diagnostic criteria for ADHD, but others lacked key features of the disorder. In addition, in the case vignettes, the researchers varied
whether the child was identified as male or female. The dependent variable was whether these professionals gave a diagnosis
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of ADHD to a case. The results
showed that participants overdiagnosed ADHD, giving an ADHD
diagnosis to cases that specifically lacked important aspects
of the disorder about 17 percent of the time. Further, regardless of symptoms, boys
were two times more likely
than girls to receive such a
diagnosis. An important lesson
from this study is that professionals must be vigilant in
their application of diagnostic
criteria as they encounter
different cases. The results
also demonstrate how even professionals can fall prey to
certain biases.
Certainly, individuals who experience ADHD have symptoms
that make adjustment difficult, so it is critical that diagnosis of
the disorder be accurate. Children diagnosed with ADHD are at
heightened risk of dropping out of school, teen pregnancy, and
antisocial behavior (Barkley & others, 2002; von Polier, Vloet, &
Herpertz-Dahlmann, 2012). Adolescents and adults with ADHD
symptoms are more likely to experience difficulties at work,
while driving a car, and in interpersonal relationships; they
are also more likely to have substance abuse problems (Chang,
Lichtenstein, & Larsson, 2012; Kooij & others, 2010; Sibley &
others, 2012).
ADHD is not the only controversial diagnosis; nor is this psychological disorder the only one given a great deal of attention by pharmaceutical companies (Mash &
Wolfe, 2013). Drug companies
commonly fund research that
focuses on a disease model of
What Do You Think?
psychological disorders. Clearly,
■ Would ADHD be as contropsychological disorders are “real”
versial if the treatment did
in the sense that they lead to
not involve drugs? Why or
objectively negative outcomes in
why not?
people’s lives. The controversy
■ Do you think ADHD would be
over ADHD is a reminder of the
diagnosed as often as it is
important role of psychology reif drugs were not readily
search in clarifying and defining
available for its treatment?
diagnostic categories. Indeed, the
■ If a teacher suggested that
aim of the profession is to avoid
your child be tested for
inappropriately labeling, misdiagADHD, what would you do?
nosing, and mistreating people
who are already suffering.
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Before we begin our survey of various psychological disorders, a word of caution.
It is very common for individuals who are learning about psychological disorders to
recognize the symptoms and behaviors of disorders in themselves or in people around
them. Keep in mind that only trained professionals can diagnose a psychological
disorder.
1. All of the following are characteristics
of abnormal behavior except
A. it is typical.
B. it causes distress.
C. it is maladaptive.
D. it is deviant.
2. The medical model interprets psychological disorders as medical diseases
with a/an
A. environmental origin.
B. sociocultural origin.
C. biological origin.
D. biopsychosocial origin.
3. A central complaint about DSM-5 is that
it neglects factors such as
A. inherited tendencies toward
particular diseases.
B. age.
C. economic and employment status.
D. All of the above.
APPLY IT! 4. Since she was a little girl,
19-year-old Francesca has believed that
whenever she walks through a doorway, she
must touch the doorframe 12 times and silently count to 12 or else her mother will
die. She has never told anyone about this
ritual, which she feels is harmless, similar
to carrying a lucky charm. Which of the
following is true of Francesca’s behavior?
A. Francesca’s behavior is abnormal only
because it is different from the norm. It
is not maladaptive, nor does it cause her
distress.
B. Francesca’s behavior fits all three characteristics of abnormal behavior.
C. Francesca’s behavior is maladaptive, but
it is not abnormal because she does not
feel personal distress over her ritual.
D. Francesca’s behavior does not fit any of
the characteristics of abnormal behavior.
2 Anxiety and Anxiety-Related Disorders
Think about how you felt before a make-or-break exam or a big presentation—or perhaps
as you noticed police lights flashing behind your speeding car. Did you feel jittery and
nervous and experience tightness in your stomach? These are the feelings of normal
anxiety, an unpleasant feeling of fear and dread.
In contrast, anxiety disorders involve fears that are uncontrollable, disproportionate
to the actual danger the person might be in, and disruptive of ordinary life. They feature
motor tension ( jumpiness, trembling), hyperactivity (dizziness, a racing heart), and
apprehensive expectations and thoughts. DSM-5 recognizes 12 types of anxiety disorders.
In this section, we survey four common anxiety disorders
■
■
■
■
Generalized anxiety disorder
Panic disorder
Specific phobia
Social anxiety disorder
anxiety disorders
Disabling (uncontrollable
and disruptive) psychological disorders that feature
motor tension, hyperactivity,
and apprehensive expectations and thoughts.
as well as two disorders that are not classified as anxiety disorders but are related to the
experience of anxiety:
■
Obsessive-compulsive disorder (categorized under Obsessive-Compulsive and Related
Disorders)
■
Post-traumatic stress disorder (categorized under Trauma- and Stressor-Related Disorders)
Generalized Anxiety Disorder
When you are worrying about getting a speeding ticket, you know why you are anxious;
there is a specific cause. Generalized anxiety disorder is different from such everyday
feelings of anxiety in that sufferers experience persistent anxiety for at least 6 months
and are unable to specify the reasons for the anxiety (Freeman & Freeman, 2012). People with generalized anxiety disorder are nervous most of the time. They may worry
generalized anxiety disorder
Psychological disorder
marked by persistent anxiety for at least 6 months,
and in which the individual
is unable to specify the
reasons for the anxiety.
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about their work, relationships, or health. That worry can also take a physical toll
Recall from Chapter 2
and cause fatigue, muscle tension, stomach problems, and difficulty sleeping.
that GABA is the
What is the etiology of generalized anxiety disorder? (Etiology means the
neurotransmitter that inhibits
causes or significant preceding conditions.) Among the biological factors are
neurons from firing—it’s like the genetic predisposition, deficiency in the neurotransmitter GABA, and respiratory system abnormalities (Boschen, 2012). The psychological and socioculbrain’s brake pedal. Problems with
tural
factors include having harsh (or even impossible) self-standards, overly
GABA are often implicated in
strict and critical parents, automatic negative thoughts when feeling stressed, and
anxiety disorders.
a history of uncontrollable traumas or stressors (such as an abusive parent).
Panic Disorder
Much like everyone else, you might sometimes have a specific experience that sends you
into a panic. For example, you work all night on a paper, only to have your computer
crash before you saved your last changes, or you are about to dash across a street
just when you see a large truck coming right at you. Your heart races, your
hands shake, and you might break into a sweat.
In a panic disorder, however, a person experiences recurrent, sudden
onsets of intense terror, often without warning and with no specific cause.
Panic attacks can produce severe palpitations, extreme shortness of breath,
chest pains, trembling, sweating, dizziness, and a feeling of helplessness (Oral
& others, 2012). People with panic disorder may feel that they are having a
heart attack or going to die.
During a panic attack, the brain registers
fear as areas of the fear network of the limbic
system, including the amygdala and hippocampus, are activated (Holzschneider & Mulert,
2011). Charles Darwin, the scientist who proposed the theory of evolution, suffered from
intense panic disorder (Barloon & Noyes,
1997). Former NFL running back Earl Campbell
has dealt with this disorder.
What is the etiology of panic disorder?
Theories of the origins of panic attack take
into account biological, psychological, and
sociocultural factors (Pilecki, Arentoft, &
McKay, 2011). In terms of biological factors,
individuals may have a genetic predisposition
to the disorder (Bayoglu & others, 2012). Of
particular interest to researchers are genes that
direct the action of neurotransmitters such as
norepinephrine (Buttenschøn & others, 2011)
and GABA (Thoeringer & others, 2009).
Another brain chemical, lactate, which plays a
role in brain metabolism, has been found to be
elevated in individuals with panic disorder
(Maddock & others, 2009). Further, experimental research has shown that increasing lactate levels can produce panic attacks (Reiman
& others 1989). Other research points to the
involvement of a wider range of genes and bodily
systems, implicating genes involved in hormone
regulation (Wilson, Markie, & Fitches, 2012)
Many experts interpret Edvard Munch’s painting The Scream as an expression
and responses to stress (Esler & others, 2009).
of the terror brought on by a panic attack.
A panic attack can
be a one-time occurrence. People
with panic disorder have
recurrent attacks that
sometimes cause them to be afraid
to even leave their homes, a
condition called agoraphobia.
448 // C H A P T E R 1 2
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P s y c h o l o g ica l D iso rders
panic disorder
Anxiety disorder
in which the individual experiences recurrent,
sudden onsets of
intense terror, often without warning and with no
specific cause.
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An earlier explanation
of panic attack was called the
With respect to psychological influences, learning processes, as described in
Chapter 5, are one factor that has been considered in panic disorder. Classical
conditioning research has shown that learned associations between bodily cues
of respiration and fear can play a role in panic attacks (Acheson, Forsyth, &
Moses, 2012). Interestingly, carbon dioxide (CO2) has been found to be a very
strong conditioned stimulus for fear, suggesting that humans may be biologically
prepared to learn an association between high concentrations of CO2 and fear (Acheson,
Forsyth, & Moses, 2012; De Cort & others, 2012; Nardi & others, 2006; Schenberg,
2010). Thus, some learning researchers have suggested that at the heart of panic attacks
are the learned associations between CO2 and fear (De Cort & others, 2012).
In addition, the learning concept of generalization may apply to panic attack.
Recall that in classical conditioning, generalization means showing a conditioned
response (in this case, fear) to conditioned stimuli other than the particular one
used in learning. Research shows that individuals who suffer from panic
attacks are more likely to display overgeneralization of fear learning (Lissek
& others, 2010). Why might those who suffer from panic attacks be more
likely to show stronger and more generalized fear associations? One possibility is that the biological predispositions as well as early experiences with
traumatic life events may play a role in setting the stage for such learning
(Pilecki, Arentoft, & McKay, 2011).
In terms of sociocultural factors, in the United States, women are twice
as likely as men to have panic attacks (Altemus, 2006). Possible reasons
include biological differences in hormones and neurotransmitters (Altemus,
2006; Fodor & Epstein, 2002). Compared to men, women are more likely
to complain of distressing respiratory experiences during panic attacks
(Sheikh, Leskin, & Klein, 2002). Interestingly, a recent study showed that
healthy women are more likely to experience panic-related emotions when
exposed to air enriched with CO2 (Nillni & others, 2012).
Research also suggests that women may cope with anxiety-provoking situations
differently than men do, and these differences may explain the gender difference in panic
disorder (Schmidt & Koselka, 2000; Viswanath & others, 2012). Panic attack has been
observed in a variety of cultures, though there are some cultural differences in the experience of these attacks (Agorastos, Haasen, & Huber, 2012). For instance, in Korea, panic
attacks are less likely to include a fear of dying than is the case in other societies (Weissman
& others, 1995).
suffocation false alarm
theory. Can you see why it
was initially proposed?
Whenever you encounter
gender differences in this
discussion, ask yourself whether
men or women might be more
likely to report having problems
or to seek treatment.
Research on psychological disorders
is often based on individuals who
have reported symptoms or
sought help. If men are less likely
to report symptoms or seek
treatment, the data may
underestimate the occurrence of
psychological disorders in men.
Specific Phobia
specific phobia
Psychological
disorder in which
an individual has
an irrational,
overwhelming,
persistent fear of
a particular object
or situation.
Many people are afraid of spiders and snakes; indeed, thinking
about letting a tarantula crawl over one’s face is likely to give
anyone the willies. It is not uncommon to be afraid of particular
objects or specific environments such as extreme heights. For most
of us, these fears do not interfere with daily life. A fear becomes
a phobia when a situation is so dreaded that an individual goes
to almost any length to avoid it. A snake phobia that keeps a citydweller from leaving his apartment is clearly disproportionate to
the actual chances of encountering a snake. Specific phobia is
a psychological disorder in which an individual has an irrational,
overwhelming, peristent fear of a particular object or situation.
Specific phobias come in many forms, as shown in Figure 12.2.
Where do specific phobias come from? Approaches to answering this question typically first acknowledge that fear plays an
important role in adaptive behavior. Fear tells us when we are in
danger and need to take to action. The importance of this function
“Stephen’s fear of heights is particularly bad today.”
Used by permission of CartoonStock, www.CartoonStock.com.
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Acrophobia
Aerophobia
Ailurophobia
Algophobia
Amaxophobia
Fear of high places
Fear of flying
Fear of cats
Fear of pain
Fear of vehicles,
driving
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Arachnophobia
Astrapophobia
Cynophobia
Gamophobia
Hydrophobia
Melissophobia
Fear of spiders
Fear of lightning
Fear of dogs
Fear of marriage
Fear of water
Fear of bees
Mysophobia
Nyctophobia
Ophidiophobia
Thanatophobia
Xenophobia
Fear of dirt
Fear of darkness
Fear of nonpoisonous
snakes
Fear of death
Fear of strangers
FIGURE 12.2 Specific Phobias This figure features examples of specific phobias—anxiety disorders characterized by irrational and overwhelming fear of
a particular object or situation.
suggests that fears should be relatively quickly learned, because learning to fear things that
will harm us keeps us out of harm’s way. Specific phobias, then, might be considered, an
extreme and unfortunate variant on this adaptive process (Coelho & Purkis, 2009; Muris
& Merckelbach, 2012).
Many explanations of specific phobias view these disorders as based on experiences,
memories, and learned associations (Veale & others, 2013). For example, the individual
with a fear of heights perhaps experienced a fall from a high place earlier in life and
therefore associates heights with pain (a classical conditioning explanation). Alternatively, he or she may have heard about or watched others who demonstrated terror of
high places (an observational learning explanation), as when a little girl develops a fear
of heights after sitting next to her terrified mother and observing her clutch the handrails,
white-knuckled, as the roller coaster creeps steeply uphill. Not all people who have a
specific phobia can easily identify experiences that explain these, so other factors may
also be at play (Coelho & Purkis, 2009). Each specific phobia may have its own neural
correlates (Lueken, 2011), and some people may be especially prone to develop phobias
(Burstein & others, 2012).
Social Anxiety Disorder
Imagine how you might feel just before you first meet the parents of the person you
hope to marry. You might feel fearful of committing some awful gaff, ruining the
impression you hope to make on them. Or imagine getting ready to give a big speech
before a crowd and suddenly realizing you have forgotten your notes. Social anxiety
disorder (also called social phobia) is an intense fear of being humiliated or
embarrassed in social situations like these (Lampe & Sutherland, 2013; Morrison &
Heimberg, 2013). Singers Carly Simon and Barbra Streisand have dealt with social
phobia.
Where does social anxiety disorder come from? Genes appear to play a role
(Sakolsky, McCracken, & Nurmi, 2013), along with neural circuitry involving the
thalamus, amygdala, and cerebral cortex (Damsa, Kosel, & Moussally, 2009). A number of neurotransmitters also may be involved, especially serotonin (Christensen
& others, 2010). Social anxiety disorder may involve vulnerabilities, such as
genetic characteristics or parenting styles that lay a foundation of risk, combined
with learning experiences in a social context (Higa-McMillen & Besutani, 2011;
Pejic & others, 2013).
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P s y c h o l o g ica l D iso rders
Social anxiety
disorder (social
phobia)
An intense fear of
being humiliated
or embarrassed in
social situations.
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In the DSM-5, generalized anxiety disorder, panic disorder, specific phobia, and social anxiety disorder are
all classified as anxiety disorders (Andrews, 2014;
Gallo & others, 2013). Our next two topics, obsessivecompulsive disorder and post-traumatic stress disorder,
are not included under the umbrella of Anxiety Disorders. Instead, these disorders have their own separate
categories. Nonetheless, anxiety is relevant to both of
these disorders.
Obsessive-Compulsive
Disorder
obsessivecompulsive
disorder (OCD)
Anxiety disorder
in which the individual has anxietyprovoking
thoughts that will
not go away and/
or urges to perform repetitive,
ritualistic behaviors to prevent or
produce some
future situation.
“I gotta go—we’re discussing my compulsive
communications disorder.”
Used by permission of CartoonStock, www.CartoonStock.com.
Just before leaving on a long road trip, you find yourself checking to be sure you locked
the front door. As you pull away in your car, you are stricken with the thought that you
forgot to turn off the coffeemaker. Going to bed the night before an early flight, you
check your alarm clock a few times to be sure you will wake up on time. These are
examples of normal checking behavior.
In contrast, the disorder known as obsessive-compulsive disorder (OCD) features
anxiety-provoking thoughts that will not go away and/or urges to perform repetitive,
ritualistic behaviors to prevent or produce some future situation. Obsessions are recurrent
thoughts, and compulsions are recurrent behaviors. Individuals with OCD dwell on their
doubts and repeat their routines sometimes hundreds of times a day (Yap, Mogan, &
Kyrios, 2012). The most common compulsions are excessive checking, cleansing, and
counting. Game show host Howie Mandel has coped with OCD, as have soccer star
David Beckham, singer-actor Justin Timberlake, and actress Jessica Alba. Obsessivecompulsive symptoms have been found in many cultures, and culture plays a role in the
content of obsessive thoughts or compulsive behaviors (Matsunaga & Seedat, 2011).
An individual with OCD might believe that she has to touch the doorway with her
left hand whenever she enters a room and count her steps as she walks. If she does
not complete this ritual, she may be overcome with a sense of fear that something
terrible will happen (Victor & Bernstein, 2009).
What is the etiology of obsessive-compulsive disorder? In terms of biological factors, there seems to be a genetic component (Alonso & others,
2012; Angoa-Perez & others, 2012). Also, brain-imaging studies have suggested neurological links for OCD (Hou & others, 2012; Stern & others,
2012). One neuroscientific analysis is that the frontal cortex or basal ganglia
are so active in OCD that numerous impulses reach the thalamus, generating
obsessive thoughts or compulsive actions (Rotge & others, 2009).
In one study, fMRI was used to examine the brain activity of individuals with
OCD before and after treatment (Nakao & others, 2005). Following effective treatment, a number of areas in the frontal cortex showed decreased activation. Interestingly, the amygdala, which is associated with the experience of anxiety, may be
smaller in individuals with OCD compared to those who do not have the disorder
(Atmaca & others, 2008). Low levels of the neurotransmitters serotonin and dopamine
likely are involved in the brain pathways linked with OCD (Goljevscek & Carvalho,
2011; Soomro, 2012).
In terms of psychological factors, OCD sometimes occurs during a period of life stress
such as that surrounding the birth of a child or a change in occupational or marital status (Uguz & others, 2007). According to the cognitive perspective, what differentiates
individuals with OCD from those who do not have it is the ability to turn off negative,
intrusive thoughts by ignoring or effectively dismissing them (Leahy, Holland, & McGinn,
2012; C. Williams, 2012).
E X PE R I E N C E I T !
Obsessive-Compulsive
Disorder
As long as the person
performs the ritual, she never
finds out that the terrible
outcome doesn’t happen. T he
easing of the anxiety exemplifies
negative reinforcement
(having something bad taken away
after performing a behavior).
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OCD-Related Disorders
DSM-5 expanded the disorders that are thought to be related to OCD (Abramowitz &
Jacoby, 2014). All of these disorders involve repetitive behavior and often anxiety. Among
the new additions are the following.
■
■
■
■
Hoarding disorder involves compulsive collecting, poor organization skills, and difficulty discarding things, along with cognitive deficits in information processing
speed, problems with decision making, and procrastination (Tolin, 2008). Individuals
with hoarding disorder find it difficult to throw things away and are troubled by the
feeling that they might need items like old newspapers at a later time (Dimauro &
others, 2013).
Excoriation (or skin picking) refers to the particular compulsion of picking at one’s
skin, sometimes to the point of injury. Skin picking is more common among women
than men and is seen as a symptom of autism spectrum disorder.
Trichotillomania (hair pulling) entails compulsively pulling at the hair from the scalp,
eyebrows, and other body areas (Walther & others, 2013). Hair pulling from the scalp
can lead to bald patches that the person can go to great lengths to disguise.
Body Dysmorphic Disorder involves a distressing preoccupation with imagined or
slight flaws in one’s physical appearance (Kaplan & others, 2013). Individuals with
this disorder cannot stop thinking about how they look and repeatedly compare their
appearance to others, check themselves in the mirror, and so forth. Body dysmorphic
disorder may include maladaptive behaviors such as compulsive exercise and body
building and repeated cosmetic surgery and occurs about equally in men and women.
Post-Traumatic Stress Disorder
post-traumatic stress
disorder (PTSD)
Anxiety disorder that develops through exposure to a
traumatic event, a severely
oppressive situation, cruel
abuse, or a natural or an
unnatural disaster.
If you have ever been in even a minor car accident, you may have had a nightmare or
two about it. You might have even found yourself reliving the experience for some time.
This normal recovery process takes on a particularly devastating character in posttraumatic stress disorder (PTSD), develops through exposure to a traumatic event that
overwhelms the person’s abilities to cope (Beidel, Bulik, & Stanley, 2012). The DSM-5
has expanded the kinds of experiences that might foster PTSD, recognizing that the
disorder can occur not only in individuals who directly experience a trauma but also in
those who witness it and those who only hear about it (APA, 2013). The symptoms of
PTSD vary but include:
■
■
■
■
■
■
Flashbacks in which the individual relives the event. A flashback can make the person
lose touch with reality and reenact the event for seconds, hours, or, very rarely, days.
A person having a flashback—which can come in the form of images, sounds, smells,
and/or feelings—usually believes that the traumatic event is happening all over again
(Brewin, 2012).
Avoiding emotional experiences and avoiding talking about emotions with others.
Reduced ability to feel emotions, often reported as feeling numb.
Excessive arousal, resulting in an exaggerated startle response or an inability to sleep.
Difficulties with memory and concentration.
Impulsive behavior.
PTSD symptoms can follow a trauma immediately or after months or even years (Solomon
& others, 2012). Most individuals who are exposed to a traumatic event experience some
of the symptoms in the days and weeks following exposure (National Center for PTSD,
2012). However, not every individual exposed to the same event develops PTSD (Brewin
& others, 2012; Nemeroff & others, 2006).
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PSYCHOLOGY IN OUR WORLD
The Psychological Wounds of War
P
TSD has been a concern for soldiers who have served in Iraq and Afghanistan
(Klemanski & others, 2012; Yoder & others, 2012). In an effort to prevent PTSD,
the U.S. military gives troops stress-management training before deployment (Ritchie
& others, 2006). Branches of the armed forces station mental health professionals in
combat zones around the world to help prevent PTSD and to lessen the effects of the
disorder (Rabasca, 2000). These measures appear to be paying off: Researchers have
found that PTSD sufferers from the Iraq and Afghanistan wars are generally less likely to
be unemployed or incarcerated and more likely to maintain strong social bonds following
their term of service than veterans of earlier wars (Fontana & Rosenheck, 2008).
Historically, the stigma associated with psychological disorders has been especially
strong within the military ranks, where struggling with a psychological problem is commonly viewed as a sign of weakness or incompetence (Warner & others, 2011). Yet individuals engaged in combat are at considerable risk of developing PTSD, and the disorder
can profoundly affect their lives. A survey of almost 3,000 soldiers who had just returned
from the Iraq War revealed that 17 percent met the criteria for PTSD (Hoge & others, 2007).
This figure is likely an underestimate given the stigma linked to psychological disorders in the military.
In 2008, military psychologist John Fortunato suggested that veterans with PTSD ought to be
eligible for the Purple Heart, the prestigious military decoration awarded to those who have been
physically wounded or killed in combat (Schogol, 2009). Awarding PTSD sufferers the Purple Heart,
Fortunato argued, would not only acknowledge their sacrifice but also reduce the stigma attached
to psychological disorders. That year, the military did consider whether PTSD sufferers in its ranks
ought to be awarded the Purple Heart. However, the Pentagon decided against awarding the Purple
Heart to military personnel with PTSD on the grounds that the disorder is not limited to victims
of physical trauma from enemy fire but also can affect eyewitnesses (Schogol, 2009). Still, the fact
that the top brass considered the possibility suggests that the military is becoming more aware of
the serious problems facing those who are traumatized while serving their country in combat.
Researchers have examined PTSD associated with various experiences (Harder & others,
2012). These include combat and war-related
traumas (Khamis, 2012), sexual abuse and
assault (S. Y. Kim & others, 2012), natural
disasters such as hurricanes and earthquakes
(Sezgin & Punamaki, 2012), and unnatural
disasters such as plane crashes and terrorist
attacks (Luft & others, 2012).
Clearly, one cause of PTSD is the traumatic
event itself (Risbrough & Stein, 2012). However, because not everyone who experiences the
same traumatic life event develops PTSD, other
factors, aside from the event, must influence a
person’s vulnerability to the disorder (GabertQuillen & others, 2012). These include a history of previous traumatic events and conditions,
such as abuse and psychological disorders
Prior to deployment, U.S. troops receive stress-management training aimed
at helping to prevent PTSD and other disorders that might be triggered by
the high-stress conditions of war.
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(Canton-Cortes, Canton, & Cortes, 2012), cultural background as in the case of traumatized
refugees (Hinton & others, 2012), and genetic predisposition (Mehta & Binder, 2012;
Skelton & others, 2012).
1. Sudden episodes of extreme anxiety or
terror that involve symptoms such as
heart palpitations, trembling, sweating, and fear of losing control are
characteristic of
A. generalized anxiety disorder.
B. post-traumatic stress disorder.
C. obsessive-compulsive disorder.
D. panic disorder.
2. Which of the following is true of
post-traumatic stress disorder?
A. It is caused by panic attacks.
B. It is the natural outgrowth of
experiencing trauma.
C. It involves flashbacks.
D. The symptoms always occur
immediately following a trauma.
3. An irrational, overwhelming, persistent
fear of a particular object or situation
is a defining characteristic of
A. post-traumatic stress disorder.
B. specific phobia.
C. panic disorder.
D. generalized anxiety disorder.
has told Tina that she is having trouble
sleeping and experiencing racing thoughts
of all the terrible things that might happen
at any given moment. Tina’s mother is
showing signs of
A. panic disorder.
B. obsessive-compulsive disorder.
C. generalized anxiety disorder.
D. post-traumatic stress disorder.
APPLY IT!
4. Lately Tina has noticed
that her mother appears to be overwhelmed
with worry about everything. Her mother
Disorders Involving
3 Emotion and Mood
Our emotions and moods tell us how we are doing in life. We feel good or bad depending on our progress on important goals, the quality of our relationships, and so on.
For some individuals, however, the link between life experiences and emotions is
off-kilter. They may feel sad for no reason or a sense of elation in the absence of any
great accomplishment. Several psychological disorders involve this kind of dysregulation in a person’s emotional life. In this section we examine the two such disorders—
depressive disorders and bipolar disorders—and consider a tragic correlate of these
disorders: suicide.
Depressive Disorders
depressive disorders
Mood disorders in which
the individual suffers from
depression—an unrelenting
lack of pleasure in life.
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Everyone feels blue sometimes. A romantic breakup, the death of a loved one, or a
personal failure can cast a dark cloud over life. Sometimes, however, a person might
feel unhappy and not know why. Depressive disorders are disorders in which the
individual suffers from depression, an unrelenting lack of pleasure in life. Depressive
disorders are common. A representative U.S. survey including individuals aged 13 and
up found that approximately 30 percent reported a depressive episode or diagnosis in
the last 12 months (Kessler & others, 2012).
A variety of cultures have recognized depression, and studies have shown that
across cultures depression is characterized as involving an absence of joy, low energy,
and high levels of sadness (Dritschel & others, 2011; Kahn, 2012). Moreover, culture
may influence the ways individuals describe their experience. For instance, people
from Eastern cultures may be less likely to talk about their emotional states, and
more likely to describe depressive symptoms in terms of bodily feelings and symptoms, than those from Western cultures (Draguns & Tanaka-Matsumi, 2003). Many
//
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major depressive
disorder (MDD)
Psychological
disorder involving a major depressive episode
and depressed
characteristics,
such as lethargy
and hopelessness, for at least
two weeks.
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successful individuals have been diagnosed with depression. They
include musicians Sheryl Crow and Eric Clapton, actors Drew Barrymore, Halle Berry, and Jim Carrey, artist Pablo Picasso, astronaut
Buzz Aldrin (the second moon walker), famed American architect
Frank Lloyd Wright, and J. K. Rowling, the author of the Harry
Potter series.
Major depressive disorder (MDD) involves a significant depressive episode and depressed characteristics, such as lethargy and hopelessness, for at least two weeks. MDD impairs daily functioning, and
the National Institute of Mental Health (NIMH) has called it the leading cause of disability in the United States (NIMH, 2008). The symptoms of major depressive disorder may include:
■
■
Depressed mood most of the day
Reduced interest or pleasure in activities that were once enjoyable
Significant weight loss or gain or significant decrease or interest in
appetite
Trouble sleeping or sleeping too much
Fatigue or loss of energy
Feeling worthless or guilty in an excessive or inappropriate manner
Problems in thinking, concentrating, or making decisions
Recurrent thoughts of death and suicide
■
No history of manic episodes (periods of euphoric mood)
■
■
■
■
■
■
This painting by Vincent Van Gogh, Portrait of
Dr. Gachet, reflects the extreme melancholy
that characterizes the depressive disorders.
Individuals who experience less-extreme depressive mood for more than two months
may be diagnosed with persistent depressive disorder. This disorder includes symptoms
such as hopelessness, lack of energy, poor concentration, and sleep problems.
What are the causes of depressive disorders? A variety of biological, psychological,
and sociocultural factors have been implicated in their development.
BIOLOGICAL FACTORS
Genetic influences play a role in depression (Goenjian
& others, 2012; Sabunciyan & others, 2012). In addition, specific brain structures are
involved in depressive disorders. For example, depressed individuals show lower levels
of brain activity in a section of the prefrontal cortex that is involved in generating actions
(Duman & others, 2012) as well as in regions of the brain associated with the perception
of rewards in the environment (Howland, 2012). A depressed person’s brain may not
recognize opportunities for pleasurable experiences.
Depression also likely involves problems in neurotransmitter regulation. Recall that
neurotransmitters are chemicals that carry impulses from neuron to neuron. For smooth
brain function, neurotransmitters must ebb and flow, often in harmony with one another.
Individuals with major depressive disorder appear to have too few receptors for the
neurotransmitters serotonin and norepinephrine (Houston & others, 2012; H. F. Li &
others, 2012). Some research suggests that problems in regulating a neurotransmitter
called substance P might be involved in depression (Munoz & Covenas, 2012). Substance
P is thought to play an important role in the psychological experience of pain (Sacerdote
& Levrini, 2012).
PSYCHOLOGICAL FACTORS
Psychological explanations of depression have
drawn on behavioral learning theories and cognitive theories. One behavioral view of
depression focuses on learned helplessness, which, as we saw in Chapter 5, involves an
individual’s feelings of powerlessness after exposure to aversive circumstances over
which the person has no control. Martin Seligman (1975) proposed that learned helplessness is a reason that some people become depressed. When individuals cannot control
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their stress, they eventually feel helpless and stop trying to change their situations. This
helplessness spirals into hopelessness (Becker-Weidman & others, 2009).
Cognitive explanations of depression focus on the thoughts and beliefs that contribute
to this sense of hopelessness (Britton & others, 2012; Jarrett & others, 2012). Psychiatrist
Aaron Beck (1967) proposed that negative thoughts reflect self-defeating beliefs that
shape depressed individuals’ experiences. These habitual negative thoughts magnify and
expand depressed persons’ negative experiences (Lam, 2012). For example, a depressed
individual might overgeneralize about a minor occurrence—say, turning in a work assignment late—and think that he or she is
worthless. A depressed person might
P SYC H O L O G I CA L I N Q U I RY
view a minor setback such as getting a
D on a paper as the end of the world.
Lifetime Rate per 100 People
The accumulation of such cognitive
distortions can lead to depression
4.0
Females
(T. W. Lee & others, 2011).
Korea
The way people think can also
Males
2.5
influence the course of depression.
Depressed individuals may ruminate
6.5
on negative experiences and negative
Puerto Rico
4.5
feelings, playing them over and over
again in their minds (Nolen-Hoeksema,
2011). This tendency to ruminate is
8.5
associated with the development of
United States
3.5
depression as well as other psychological problems such as binge eating
13.0
and substance abuse (Cowdrey & Park,
Edmonton, Canada
2012; Kuhn & others, 2012).
7.5
Another cognitive view of depression focuses on people’s attributions—
16.0
their attempts to explain what caused
New Zealand
something to happen (Seidel & others,
8.0
2012). Depression is thought to be
related to a pessimistic attributional
17.0
style. In this style, individuals reguWest Germany
5.0
larly explain negative events as having
internal causes (“It is my fault I failed
the exam”), stable causes (“I’m going
19.0
to fail again and again”), and global
Florence, Italy
6.5
causes (“Failing this exam shows that
I won’t do well in any of my courses”).
22.0
Pessimistic attributional style means
Paris, France
blaming oneself for negative events
11.0
and expecting the negative events
to recur (Abramson, Seligman, &
24.0
Teasdale, 1978). This pessimistic style
Beirut, Lebanon
can be contrasted with an optimistic
14.0
attributional style, which is essentially
its opposite. Optimists make external
0
5
10
15
20
25
30
attributions for bad things that happen
FIGURE 12.3 Gender Differences in Depression Across Cultures
(“I did badly on the test because it’s
This graph shows the rates of depression for men and women in nine cultures (Weissman
hard to know what a professor wants
& Olfson, 1995). > Which cultures have the highest and lowest rates of depression?
on the first exam”). They also recogWhat might account for these differences? > Which cultures have the largest gender
nize that these causes can change (“I’ll
difference in depression? What might account for these differences? > In order to be
do better on the next one”) and that
diagnosed with depression, a person has to seek treatment for the disorder. How might
they are specific (“It was only one
gender and culture influence a person’s willingness to get treatment?
test”). Optimistic attributional style
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has been related to lowered depression and decreased suicide risk in a variety of samples (Rasmussen & Wingate, 2012; Tindle & others, 2012).
Having a spouse, roommate, or friend who suffers from depression can increase the
risk that an individual will also become depressed (Coyne, 1976; Joiner, Alfano, & Metalsky,
1992; Ruscher & Gotlib, 1988). Such effects are sometimes called contagion because
they suggest that depression can spread from one person to another (Kiuru & others,
2012). Of course, the term contagion here is metaphorical. In fact, research suggests that
whether depression and anxiety are contagious depends on the quality of interactions
between people. To read more about this topic and its potential role in children’s psychological health, see the Intersection.
SOCIOCULTURAL FACTORS
Individuals with a low socioeconomic status
(SES), especially people living in poverty, are more likely to develop depression than
their higher-SES counterparts (Boothroyd & others, 2006). A longitudinal study of adults
revealed that depression increased as one’s standard of living and employment circumstances worsened (Lorant & others, 2007). Studies have found very high rates of depression in Native American groups, among whom poverty, hopelessness, and alcoholism are
widespread (Teesson & Vogl, 2006).
Women are nearly twice as likely as men to develop depression (Yuan & others,
2009). As Figure 12.3 shows, this gender difference occurs in many countries
(Inaba & others, 2005). Incidence of depression is high, too, among single women
who are the heads of households and among young married women who work at
unsatisfying, dead-end jobs (Whiffen & Demidenko, 2006). Minority women also
are a high-risk group for depression (Diefenbach & others, 2009).
Another gender
difference to consider: Why
might men show lower levels of
depression than women?
Bipolar Disorder
80
70
Percent risk of bipolar disorder
bipolar disorder
Mood disorder
characterized by
extreme mood
swings that include one or
more episodes of
mania, an overexcited, unrealistically optimistic
state.
Just as we all have down times, there are times when things seem to
be going phenomenally well. For individuals with bipolar disorder, the
ups and downs of life take on an extreme and often harmful tone.
Bipolar disorder is a disorder characterized by extreme mood swings
that include one or more episodes of mania, an overexcited, unrealistically optimistic state. A manic episode is like the flipside of a depressive episode (Goldney, 2012). The person who experiences mania
feels on top of the world. She has tremendous energy and might sleep
very little. A manic state also features an impulsivity that can get the
individual in trouble. For example, the sufferer might spend his life
savings on a foolish business venture.
Most bipolar individuals experience multiple cycles of depression
interspersed with mania, usually separated by six months to a year.
Unlike depressive disorders, which are more likely to occur in women,
bipolar disorder is equally common in women and men. Bipolar disorder does not prevent a person from being successful. Award-winning
actor Catherine Zeta-Jones, famed dancer and choreographer Alvin
Ailey, and actor-writer Carrie Fisher (Princess Leia) have been diagnosed with bipolar disorder.
What factors play a role in the development of bipolar disorder?
Genetic influences are stronger predictors of bipolar disorder than of
depressive disorders (Pirooznia & others, 2012). An individual with
an identical twin who has bipolar disorder has a 70 percent probability of also having the disorder, and a fraternal twin has a more than
10 percent probability (Figure 12.4). Researchers are zeroing in on
the specific genetic location of bipolar disorder (Crisafulli & others,
2012; Pedroso & others, 2012).
60
50
40
30
20
10
0
Identical
twins
Fraternal
twins
General
population
FIGURE 12.4 Risk of Bipolar
Disorder in Identical and Fraternal
Twins If One Twin Has the Disorder,
and in the General Population Notice how
much stronger the similarity of bipolar disorder is in
identical twins as compared with fraternal twins and
the general population. These statistics suggest a
strong genetic role in the disorder.
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INTERSECTION
Clinical and Developmental Psychology:
Can Kids “Catch” Depression and Anxiety?
T
he role of friendships in children’s and adolescents’ lives
is increasingly of interest to
developmental psychologists.
Among youth, friends are important to
self-esteem, well-being, and school
adjustment (Mendel & others, 2012;
Mora & Gil, 2012; Shany, Wiener, &
Assido, 2012). Still, some friends
may be better influences than others.
A large body of evidence supports the
conclusion that hanging around with
friends who engage in problem behaviors such as delinquency and substance abuse increases the likelihood
of youth involvement in such behavior
(Giletta & others, 2012; Laursen &
others, 2012). But what about associating closely with individuals
who have psychological symptoms, like depression and anxiety,
that are not as likely to be evident in behavior? Might such symptoms also “rub off” on friends?
Before addressing that question, let’s clarify some terms. In
children, symptoms of psychological disorders are often categorized as either externalizing or internalizing symptoms. Externalizing symptoms, commonly referred to as “acting out,” include
delinquency and aggression. Internalizing symptoms include
feelings of depression and anxiety. While research supports the
notion that externalizing symptoms are contagious (that is, they
spread from one friend to another), only recently have researchers addressed the possibility that internalizing symptoms might
be contagious as well. To put it concretely, can having a friend
who is depressed or anxious increase the likelihood that a
child or an adolescent will become depressed or anxious as
well? Research suggests the answer is yes (Prinstein, 2007;
Tompkins & others, 2011), and a recent study by Rebecca
Schwartz-Mette and Amanda Rose (2012) provides an explanation for this effect.
These researchers proposed that depression and anxiety can
pass from one friend to another through the conversations friends
share. They examined a particular kind of social sharing called corumination (Rose, 2002; Rose & Smith, 2009). Rumination is a
way of thinking that involves worrying about a topic without finding
a resolution. When we ruminate, we might dwell on all the possible horrible consequences of some negative event or imagine
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P s y c h o l o g ica l D iso rders
everything that might go wrong in the
future. Co-rumination is like that too,
but it involves engaging in a conversation with someone and making a negative event that the person is going
through seem even worse. When
friends co-ruminate, they focus on
problems, rehashing them repeatedly,
speculating on possible future problems, and emphasizing negative emotions (Rose, 2002). Ironically, though
co-rumination can make both members of a friendship feel pretty miserable, this kind of social sharing is
also related to friendship quality and
closeness (Rose, Carlson, & Waller,
2007). Perhaps because of this
closeness, co-rumination is associated with strong feelings of empathetic distress, which occurs when one friend takes on the negative feelings of the other (Smith & Rose, 2011). If co-ruminating
allows one to share deeply in the emotional life of another, it
might well play a role in spreading depression or anxiety.
To explore this possibility, Schwartz-Mette and Rose (2012)
examined whether symptoms of depression and anxiety in one youth
predicted increases in these symptoms in that individual’s friends
and whether this contagion might be explained by the tendency to
co-ruminate. They surveyed several hundred children (third- and fifthgraders) and adolescents (seventh- and ninth-graders) and their best
friends and found that having a friend who was feeling depressed
or anxious indeed predicted increases in feelings of depression or
anxiety six months later in all but the youngest boys. Further, corumination was associated with contagion of anxiety for all but the
youngest boys in the study. For depression, co-rumination was associated with the contagion of depression but only for adolescents.
This work shows that peer relationships are a key factor to consider in
\\ How do these results
psychological difficulties among youth.
match your experiences of
Friends are a vital resource, and
childhood friendship?
talking with friends is a primary channel by which we make sense of the
\\ Do some of your
world. Research is now showing that
present-day friends
the quality of those conversations
co-ruminate over negative
may be an important element in
mental health.
events?
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Other biological processes are also a factor. Like depression, bipolar disorder is
associated with differences in brain activity.
Figure 12.5 shows the metabolic activity in
the cerebral cortex of an individual cycling
through depressive and manic phases. Notice
the decrease in metabolic activity in the
brain during depression and the increase in
metabolic activity during mania (Baxter &
others, 1995). In addition to high levels of
norepinephrine and low levels of serotonin,
studies link high levels of the neurotransmitter glutamate to bipolar disorder (Singh &
others, 2010; Sourial-Bassillious & others,
2009).
Psychologists and psychiatrists have
recently noted cases of children who appear
to suffer from bipolar disorder (Cosgrove,
Roybal, & Chang, 2013; Defilippis & Wagner,
2013). A key dilemma in such cases is that
treating bipolar disorder in adults involves
administering psychoactive drugs that have
not been approved for children’s use. The
side effects of these drugs could put chil- FIGURE 12.5 Brain Metabolism in Mania and Depression
dren’s health and development at risk. To PET scans of an individual with bipolar disorder, who is described as a rapid-cycler
address this issue, DSM-5 includes a new because of how quickly severe mood changes occurred. (Top and bottom) The
diagnosis, disruptive mood dysregulation person’s brain in a depressed state. (Middle) A manic state. The PET scans reveal
how the brain’s energy consumption falls in depression and rises in mania. The red
disorder, which is considered a depressive
areas in the middle row reflect rapid consumption of glucose.
disorder in children who show persistent
irritability and recurrent episodes of out-of-control behavior (APA, 2013). This decision
is not without controversy. As we saw with ADHD, some children who are perceived to
be prone to wild mood swings may be simply behaving like children.
Suicide
Thinking about suicide is not necessarily abnormal. However, attempting or completing
the act of suicide is abnormal. Approximately 90 percent of individuals who commit
suicide are estimated to have a diagnosable mental disorder (NIMH, 2008), and the most
common disorders among individuals who commit suicide are depression and anxiety
(Blanco & others, 2012; Nauta & others, 2012). Depressed individuals are also likely to
attempt suicide more than once (da Silva Cais & others, 2009). Sadly, many individuals
who, to the outside eye, seem to be leading successful and fulfilling lives have ended their
lives through suicide. Examples include poet Sylvia Plath, novelist Ernest Hemingway,
and grunge icon Kurt Cobain (who committed suicide after lifelong battles with ADHD
and bipolar disorder).
According to the Centers for Disease Control and Prevention (CDC), in 2010, 37,793
people in the United States committed suicide, and suicide was the 10th-highest cause
of death in the country (CDC, 2012). There are twice as many suicides as homicides in
the United States, and the suicide rate increased 13 percent from 1999 to 2010 (Schmitz
& others, 2012). Research indicates that for every completed suicide, 8 to 25 attempted
suicides occur (NIMH, 2008). Suicide is the third-leading cause (after automobile accidents and homicides) of death today among U.S. adolescents 13 through 19 years of age
(Murphy, Xu, & Kochanek, 2012). Even more shocking, in the United States suicide is
the third-leading cause of death among children 10 to 14 years of age (CDC, 2007).
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What to Do
1. Ask direct, straightforward questions in a calm
manner. For example, “Are you thinking about
hurting yourself?”
2. Be a good listener and be supportive. Emphasize
that unbearable pain can be survived.
3. Take the suicide threat very seriously. Ask
questions about the person’s feelings, relationships, and thoughts about the type of method to
be used. If a gun, pills, rope, or other means is
mentioned and a specific plan has been
developed, the situation is dangerous. Stay with
the person until help arrives.
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Given these grim statistics, psychologists work with individuals to reduce the frequency and intensity of suicidal
impulses. Figure 12.6 provides good advice on what to do
and what not to do if you encounter someone who is threatening suicide.
What might prompt an individual to end his or her own
life? Biological, psychological, and sociocultural circumstances can be contributing factors.
BIOLOGICAL FACTORS Genetic factors appear to play
3. Don’t react with horror,
disapproval, or repulsion.
a role in suicide, which tends to run in families (Althoff &
others, 2012). The Hemingways are one famous family that
has been plagued by suicide. Five Hemingways, spread across
generations, committed suicide, including the writer Ernest
Hemingway and his granddaughter Margaux, a model
and actor. Similarly, in 2009, Nicholas Hughes—a
successful marine biologist and the son of Sylvia
Plath, a poet who had killed herself—tragically
hanged himself.
Studies have linked suicide with low levels of
the neurotransmitter serotonin (Lyddon & others,
2012). Individuals who attempt suicide and who
have low serotonin levels are 10 times more likely
to attempt suicide again than are attempters who
have high serotonin levels (Courtet & others, 2004).
Poor physical health, especially when it is chronic, is
another risk factor for suicide (Webb & others, 2012).
4. Don’t offer false reassurances
(“Everything will be all right”) or make judgments
(“You should be thankful for . . .”).
PSYCHOLOGICAL FACTORS
4. Encourage the person to get professional help
and assist him or her in getting help.
If the person is willing, take
the person to a mental
health facility
or hospital.
What Not to Do
1. Don’t ignore
the warning signs.
2. Don’t refuse to
talk about suicide if
the person wants to
talk about it.
Psychological factors
that can contribute to suicide include mental disorders and
traumas such as sexual abuse (Wanner & others, 2012).
Struggling with the stress of a psychological disorder can
leave a person feeling hopeless, and the disorder itself may
FIGURE 12.6 When Someone Is Threatening
tax the person’s ability to cope with life’s difficulties.
Suicide Do not ignore the warning signs if you think someone
Indeed, approximately 90 percent of individuals who comyou know is considering suicide. Talk to a counselor if you are
mit suicide are estimated to have a diagnosable mental disreluctant to say anything to the person yourself.
order (NIMH, 2008).
An immediate and highly stressful circumstance—such as the loss of a loved one or
a job, flunking out of school, or an unwanted pregnancy—can lead people to threaten
and/or to commit suicide (Videtic & others, 2009). In addition, substance abuse is linked
with suicide more today than in the past (Conner & others, 2012).
In research focusing on suicide notes, Thomas Joiner and his colleagues have found
that having a sense of belongingness or of being needed separates individuals who
attempt suicide from those who complete it (Joiner, 2005; Joiner, Hollar, & Van
Orden, 2006; Joiner & Ribeiro, 2011). Essentially, people who feel that someone
will miss them or still need them are less likely than others to complete a suicide
(A. R. Smith & others, 2012).
5. Don’t abandon the person after the crisis seems
to have passed or after professional counseling
has begun.
Note that people whose
parents committed suicide may be
more likely to consider suicide as
an option. So, environment
matters.
SOCIOCULTURAL FACTORS Chronic economic hardship can be a factor in suicide (Ferretti & Coluccia, 2009; Rojas & Stenberg, 2010). Cultural and ethnic contexts
also are related to suicide attempts. In the United States, adolescents’ suicide attempts
vary across ethnic groups. As Figure 12.7 illustrates, more than 20 percent of Native
American/Alaska Native (NA/AN) female adolescents reported that they had attempted
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Suicide attempt rates (per 100)
24
suicide in the previous year, and suicide
African American
Latino
accounts for almost 20 percent of NA/AN
NA/AN
Non-Latino
20
deaths in 15- to 19-year-olds (Goldston
White
AA/PI
& others, 2008). As the figure also shows,
16
African American and non-Latino White
males reported the lowest incidence of
12
suicide attempts. A major risk factor
in the high rate of suicide attempts by
8
NA/AN adolescents is their elevated rate
of alcohol abuse.
4
Suicide rates vary worldwide; the lowest rates occur in countries with cultural
0
and religious norms against ending one’s
Males
Females
own life. Among the nations with the
highest suicide rates are several eastern FIGURE 12.7 Suicide Attempts by U.S. Adolescents from
European nations—including Belarus, Different Ethnic Groups Note that the data shown are for one-year rates of
self-reported suicide attempts. NA/AN ⫽ Native Americans/Alaska Native; AA/PI ⫽
Bulgaria, and Russia—along with Japan
Asian American/Pacific Islander.
and South Korea. According to the World
Health Organization (WHO), among the
nations with the lowest rates are Haiti, Antigua and Barbuda, Egypt, and Iran (WHO,
2009). Of the 104 nations ranked by the WHO, the United States ranks 40th.
Research has also linked suicide to the culture of honor. Recall that in honor cultures, individuals are more likely to interpret insults as fighting words and to defend
their personal honor with aggression. One set of studies examined suicide and depression in the United States, comparing geographic regions that are considered to have
a culture of honor (that is, southern states) with other areas. Even accounting for a
host of other factors, suicide rates were found to be higher in states with a culture of
honor (Osterman & Brown, 2011). The researchers also examined how regions compared in terms of the use of prescription antidepressants and discovered that states
with a culture of honor also had lower levels of use of these drugs. It may be that
in a culture of honor, seeking treatment for depression is seen as a weakness
or a mark of shame.
There are gender differences in suicide as well (Sarma & Kola, 2010).
Women are three times more likely than men to attempt suicide. Men, however,
are four times more likely than women to complete suicide (Kochanek & others, 2004). Men are also more likely than women to use a firearm in a suicide
attempt (Maris, 1998). The highest suicide rate is among non-Latino White men
ages 85 and older (NIMH, 2008).
Men are less likely
than women to report being
depressed but are more likely to
commit suicide. Clearly,
depression in men might be
underestimated.
1. To be diagnosed with bipolar disorder,
an individual must experience
A. a manic episode.
B. a depressive episode.
C. a manic episode and a depressive
episode.
D. a suicidal episode.
2. All of the following are a symptom of
major depressive disorder except
A. fatigue.
B. weight change.
C. thoughts of death.
D. substance use.
3. A true statement about suicide and
gender is that
A. women are more likely to attempt
suicide than men.
B. men are more likely to attempt
suicide than women.
C. men and women are equally likely to
attempt suicide.
D. men and women are equally likely to
complete suicide.
APPLY IT!
4. During his first two college years, Barry has felt “down” most of
the time. He has had trouble concentrating
and difficulty making decisions. Sometimes
he is so overwhelmed with deciding on his
major and struggling to focus that he feels
hopeless. He has problems with loss of appetite and sleeps a great deal of the time,
and in general his energy level is low. Barry
has found that things he used to love, like
watching sports and playing video games
are just no fun anymore. Which of the following is most likely to be true of Barry?
A. Barry is suffering from major depressive
disorder.
B. Barry is entering the depressive phase of
bipolar disorder.
C. Barry has an anxiety disorder.
D. Barry is experiencing the everyday blues
that everyone gets from time to time.
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4 Eating Disorders
For some people, concerns about weight and body image become a serious, debilitating
disorder (Lock, 2012a; Wilson & Zandberg, 2012). For such individuals, the very act of
eating is an arena where a variety of complex biological, psychological, and cultural issues are played out, often with tragic consequences.
A number of famous people have coped with eating disorders, including
Princess Diana, Ashley Judd, Paula Abdul, Mary-Kate Olsen, and Kelly
Clarkson. Eating disorders are characterized by extreme disturbances in
eating behavior—from eating very, very little to eating a great deal. In this
section we examine three eating disorders—anorexia nervosa, bulimia nervosa, and binge-eating disorder.
Disorders of eating can
vary across cultures. In Fiji,
a disorder known as macake involves
poor appetite and refusing to eat.
Very high levels of social concern meet
this refusal, and individuals with
macake are strongly motivated to
start eating and
Anorexia Nervosa
enjoying food again.
anorexia nervosa
Eating disorder that involves
the relentless pursuit of
thinness through starvation.
Anorexia nervosa is an eating disorder that involves the relentless pursuit of thinness
through starvation. Anorexia nervosa is much more common in girls and women than boys
and men and affects between 0.5 and 3.7 percent of young women (NIMH, 2011). The
American Psychiatric Association (2013) lists these main characteristics of anorexia nervosa:
■
■
■
Weight less than 85 percent of what is considered normal for age and height, and
refusal to maintain weight at a healthy level.
An intense fear of gaining weight that does not decrease with weight loss.
A distorted body image (Stewart & others, 2012). Even when
individuals with anorexia nervosa are extremely thin, they never
think they are thin enough.
Over time, anorexia nervosa can lead to physical changes, such
as the growth of fine hair all over the body, thinning of bones and
hair, severe constipation, and low blood pressure (NIMH, 2011).
Dangerous and even life-threatening complications include damage
to the heart and thyroid. Anorexia nervosa is said to have the highest mortality rate (about 5.6 percent of individuals with anorexia
nervosa die within 10 years of diagnosis) of any psychological disorder (Hoek, 2006; NIMH, 2011).
Anorexia nervosa typically begins in the teenage years, often
following an episode of dieting and some type of life stress
(Fitzpatrick, 2012). Most individuals with anorexia nervosa
are non-Latino White female adolescents or young adults
from well-educated middle- and upper-income families
(Darcy, 2012; Dodge, 2012). They are often high-achieving
perfectionists (Forbush, Heatherton, & Keel, 2007). Obsessive thinking about weight and compulsive exercise are also
related to anorexia nervosa (Hildebrandt & others, 2012).
Individuals with
anorexia nervosa lack personal
distress over their symptoms.
Recall that personal distress
over one ’s behavior is just one
aspect of the definition
of abnormal.
Bulimia Nervosa
bulimia nervosa
Eating disorder in which an
individual (typically a girl or
woman) consistently follows
a binge-and-purge eating
pattern.
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Bulimia nervosa is an eating disorder in which an individual (typically female) consistently follows a binge-and-purge eating pattern.
The individual goes on an eating binge and then purges by selfinduced vomiting or the use of laxatives. Most people with bulimia
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Uruguayan model Eliana Ramos posed
for the camera in her native country.
Tragically, the super-thin Ramos died at
age 18 in February 2007, two years
after this picture was taken, reportedly
from health problems associated with
anorexia nervosa.
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n
nervosa
are preoccupied with food, have a strong fear of becomiing overweight, and are depressed or anxious (Birgegárd, Norring,
& Clinton, 2012). Because bulimia nervosa occurs within a normal
weight range, the disorder is often difficult to detect. A person with
we
bulimia nervosa usually keeps the disorder a secret and experiences
bul
a great deal of self-disgust and shame.
Bulimia nervosa can lead to complications such as a
chronic sore throat, kidney problems, dehydration, and
gastrointestinal disorders (NIMH, 2011). The disorder
iis also related to dental problems, as persistent exposure
to the
h stomach acids in vomit can wear away tooth enamel.
Bulimia nervosa typically begins in late adolescence or early adulthood (Levine,
2002). The disorder affects between 1 and 4 percent of young women (NIMH, 2011).
Like those with anorexia nervosa, many young women who develop bulimia nervosa are
highly perfectionistic (Lampard & others, 2012). At the same time, they tend to
have low levels of self-efficacy (Bardone-Cone & others, 2006). In other words,
these are young women with very high standards but very low confidence that
they can achieve their goals. Impulsivity, negative emotion, and obsessive-compulsive disorder are also related to bulimia (Roncero, Perpina, & Garcia-Soriano,
2011). Bulimia nervosa is associated, too, with a high incidence of sexual and
physical abuse in childhood (Lo Sauro & others, 2008).
Dentists and dental
hygienists are sometimes the
first to recognize the signs of
bulimia nervosa.
Although much more
common in women, bulimia can
also affect men. Elton John has
described his struggles with
this eating disorder.
Anorexia Nervosa and Bulimia Nervosa:
Causes and Treatments
What is the etiology (cause) of anorexia nervosa and bulimia nervosa? For many years
researchers thought that sociocultural factors, such as media images of very thin women
and family pressures, were the central determinants of these disorders (Le Grange &
others, 2010). Media images that glorify extreme thinness can indeed influence women’s
body image, and emphasis on the thin ideal is related to anorexia nervosa and bulimia
nervosa (Carr & Peebles, 2012). However, as powerful as these media messages might
be, countless females are exposed to media images of unrealistically thin women, but
relatively few develop eating disorders. Many young women embark on diets, but comparatively few of them develop eating disorders.
Eating disorders occur in cultures that do not emphasize the ideal of thinness,
although the disorders may differ from Western descriptions. For instance, in Eastern
cultures, individuals can show the symptoms of anorexia nervosa, but they lack the fear
of getting fat that is common in North Americans with the disorder (Pike, Yamamiya,
& Konishi, 2011).
Since the 1980s, researchers have increasingly probed the potential biological underpinnings of these disorders, examining in particular the interplay of social and biological
factors. Genes play a substantial role in both anorexia nervosa and bulimia nervosa (Lock,
2012b). In fact, genes influence many psychological characteristics (for example, perfectionism, impulsivity, obsessive-compulsive tendencies, and thinness drive) and behaviors
(restrained eating, binge eating, self-induced vomiting) that are associated with anorexia
nervosa and bulimia nervosa (Mikolajczyk, Grzywacz, & Samochowiec, 2010; Schur,
Heckbert, & Goldberg, 2010). These genes are also factors in the regulation of serotonin,
and problems in regulating serotonin are related to both anorexia nervosa and bulimia
nervosa (Capasso, Putrella, & Milano, 2009).
Even as biological factors play a role in the emergence of eating disorders, eating
disorders themselves affect the body, including the brain. Most psychologists believe that
while social factors and experiences may play a role in triggering dieting, the physical
effects of dieting, bingeing, and purging may change the neural networks that then sustain the disordered pattern, in a kind of vicious cycle (Lock, 2012b).
Eating Dis orders
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Although anorexia and bulimia nervosa are serious disorders, recovery is possible
(Fitzpatrick, 2012; Treasure, Claudino, & Zucker, 2010). Anorexia nervosa may require
hospitalization. The first target of intervention is promoting weight gain, in extreme cases
through the use of a feeding tube. A common obstacle in the treatment of anorexia nervosa is that individuals with the disorder deny that anything is wrong. They maintain
their belief that thinness and restrictive dieting are correct and not a sign of mental illness
(Wilson, Grilo, & Vitousek, 2007). Still, drug therapies and psychotherapy have been
shown to be effective in treating anorexia nervosa, as well as bulimia nervosa (Hagman
& Frank, 2012; Wilson & Zandberg, 2012).
Binge-Eating Disorder
binge-eating disorder (BED)
Eating disorder characterized by recurrent episodes
of eating large amounts of
food during which the person feels a lack of control
over eating.
Binge-eating disorder (BED) is characterized by recurrent episodes of consuming
large amounts of food during which the person feels a lack of control over eating
(APA, 2013). Unlike an individual with bulimia nervosa, someone with BED does not try
to purge. Most individuals with BED are overweight or obese (Carrard, der Linden, &
Golay, 2012).
Individuals with BED often eat quickly, eat a great deal when they are not hungry,
and eat until they are uncomfortably full. They frequently eat alone because of embarrassment or guilt, and they feel ashamed and disgusted with themselves after overeating.
BED is the most common of all eating disorders—affecting men, women, and ethnic
groups within the United States more similarly than anorexia nervosa or bulimia nervosa
(Azarbad & others, 2010). An estimated 2 to 5 percent of Americans will suffer from
BED in their lifetime (NIMH, 2011).
BED is thought to characterize approximately 8 percent of individuals who are obese.
Unlike obese individuals who do not suffer from BED, binge eaters are more likely to
place great value on their physical appearance, weight, and body shape (Grilo, Masheb,
& White, 2010). The complications of BED are those of obesity more generally, including diabetes, hypertension, and cardiovascular disease.
Binge-Eating Disorder:
Causes and Treatments
Researchers are examining the role of biological and psychological factors
in BED. Genes play a role (Akkermann & others, 2012), as does dopamine, the neurotransmitter related to reward pathways in the brain
(C. Davis & others, 2010). The fact that binge eating often occurs
after stressful events suggests that binge eaters use food to
regulate their emotions (Wilson, Grilo, & Vitousek, 2007).
The areas of the brain and endocrine system that respond
to stress are overactive in individuals with BED (Lo Sauro
& others, 2008), and this overactivity leads to high levels
of circulating cortisol, the hormone most associated with
stress. Individuals with BED may be more likely to perceive
events as stressful and then seek to manage that stress by
binge eating.
Little research has examined the sociocultural factors in BED.
One study examined whether exposure to U.S. culture might increase
the risk of developing BED (Swanson & others, 2012). The results
showed that Mexicans who immigrated to the United States and
Mexican Americans were more likely to develop BED than were
Unlike individuals with anorexia nervosa or bulimia
Mexicans who lived in Mexico, controlling for a variety of factors
nervosa, most people with binge eating disorder are
(Swanson & others, 2012).
overweight or obese.
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Just as treatment for anorexia nervosa first focuses on weight gain, some believe that
treatment for BED should first target weight loss (DeAngelis, 2002). Others argue that
individuals with BED must be treated for disordered eating per se, and they insist that if
the underlying psychological issues are not addressed, weight loss will not be successful
or permanent (de Zwaan & others, 2005; Hay & others, 2009).
1. The main characteristics of anorexia nervosa include all of the following except
A. absence of menstrual periods after
puberty.
B. distorted image of one’s body.
C. strong fears of weight gain even as
weight loss occurs.
D. intense and persistent tremors.
2. A person with bulimia nervosa typically
A. thinks a lot about food.
B. is considerably underweight.
C. is a male.
D. is not overly concerned about gaining weight.
3. The most common of all eating
disorders is
A. bulimia nervosa.
B. anorexia nervosa.
C. binge eating disorder.
D. gastrointestinal disease.
APPLY IT!
4. Nancy is a first-year
straight-A premed major. Nancy’s roommate
Luci notices that Nancy has lost a great
deal of weight and is extremely thin. Luci
observes that Nancy works out a lot, rarely
finishes meals, and wears bulky sweaters all
the time. Luci also notices that Nancy’s
arms have fine hairs growing on them, and
Nancy has mentioned never getting her
period anymore. When Luci asks Nancy
about her weight loss, Nancy replies that
she is very concerned that she not gain the
“freshman 15” and is feeling good about
her ability to keep up with her work and
keep off those extra pounds. Which of the
following is the most likely explanation for
what is going on with Nancy?
A. Nancy likely has bulimia nervosa.
B. Despite her lack of personal distress
about her symptoms, Nancy likely has
anorexia nervosa.
C. Nancy has binge eating disorder.
D. Given Nancy’s overall success, it seems
unlikely that she is suffering from a
psychological disorder.
5 Dissociative Disorders
dissociative
disorders
Psychological
disorders that
involve a sudden
loss of memory
or change in
identity due to
the dissociation
(separation) of
the individual’s
conscious awareness from previous memories
and thoughts.
Have you ever been on a long car ride and completely lost track of time, so that you
could not even remember a stretch of miles along the road? Have you been so caught
up in a daydream that you were unaware of the passage of time? These are examples of
normal dissociation. Dissociation refers to psychological states in which the person feels
disconnected from immediate experience.
At the extreme of dissociation are individuals who persistently feel a sense of
disconnection. Dissociative disorders are psychological disorders that involve a
sudden loss of memory or change in identity. Under extreme stress or shock, the
individual’s conscious awareness becomes dissociated (separated or split) from
previous memories and thoughts (Espirito-Santo & Pio-Abreu, 2009). Individuals
who develop dissociative disorders may have problems putting together different
aspects of consciousness, so that experiences at different levels of awareness might
be felt as if they are happening to someone else (Dell & O’Neil, 2007).
Psychologists believe that dissociation is a way of dealing with extreme stress
(Brand & others, 2012). Through dissociation the individual mentally protects his or her
conscious self from the traumatic event. Dissociative disorders often occur in individuals
who also show signs of PTSD (Lanius & others, 2012). Both psychological disorders
are thought to be rooted, in part, in extremely traumatic life events (Foote & others,
2006). The notion that dissociative disorders are related to problems in pulling together
emotional memories is supported by findings showing lower volume in the hippocampus and amygdala in individuals with dissociative disorders (Vermetten &
others, 2006). The hippocampus is especially involved in consolidating memory
and organizing life experience into a coherent whole (Spiegel, 2006).
Dissociative disorders are perhaps the most controversial of all diagnostic
categories, with some psychologists believing that they are often mistakenly
diagnosed (Freeland & others, 1993) and others arguing that they are underdiagnosed (Sar, Akyuz, & Dogan, 2007; Spiegel, 2006). Three kinds of dissociative
disorders are dissociative amnesia, dissociative fugue, and dissociative identity disorder.
In dissociative
disorders, consciousness (see
Chapter 4) is split off from
experience—the “stream of
consciousness” is disrupted.
Hypnosis is often used to treat
dissociative disorders.
T he study on
dissociative disorders in
Uganda from earlier in this
chapter found agreement among
respondents that dissociative
states are brought on
by trauma.
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Dissociative Amnesia
dissociative amnesia
Dissociative disorder characterized by extreme memory
loss that is caused by extensive psychological stress.
Recall from Chapter 6 that amnesia is the inability to recall important events (Markowitsch & Staniloiu, 2012). Amnesia can result from a blow to the head that produces
trauma in the brain. Dissociative amnesia is a type of amnesia characterized by extreme
memory loss that stems from extensive psychological stress. People experiencing dissociative amnesia remember everyday tasks like how to hail a cab and use a phone. They
forget only aspects of their own identity and autobiographical experiences.
Sometimes individuals suffering from dissociative amnesia will also unexpectedly
travel away from home, occasionally even assuming a new identity. For instance, on
August 28, 2008, Hannah Upp, a 23-year-old middle school teacher in New York City,
disappeared while out for a run (Marx & Didziulis, 2009). She had no wallet, no identification, no cell phone, and no money. Her family, friends, and roommates posted flyers around the city and messages on the Internet. As days went by, they became
increasingly concerned that something terrible had happened. Finally, Hannah was
found floating face down in the New York harbor on September 16, sunburned
and dehydrated but alive. She remembered nothing of her experiences. To her,
it felt like she had gone out for a run and 10 minutes later was being pulled
from the harbor. To this day, she does not know what event might have led to
her dissociative amnesia, nor does she remember how she survived during her
two-week disappearance.
At one point during her
dissociative amnesia, Hannah was
approached by someone who asked
if she was the Hannah everyone
was looking for, and she
answered no.
Dissociative Identity Disorder
dissociative identity disorder
(DID)
Formerly called multiple
personality disorder, a dissociative disorder in which
the individual has two or
more distinct personalities
or selves, each with its own
memories, behaviors, and
relationships.
Dissociative identity disorder (DID), formerly called multiple personality disorder,
is the most dramatic, least common, and most controversial dissociative disorder.
Individuals with this disorder have two or more distinct personalities or identities
(Belli & others, 2012). Each identity has its own memories, behaviors, and relationships. One identity dominates at one time, another takes over at another time. Individuals sometimes report that a wall of amnesia separates their different identities
(Dale & others, 2009); however, research suggests that memory does transfer across
these identities, even if the person believes it does not (Kong, Allen, & Glisky, 2008).
The shift between identities usually
occurs under distress (Sar & others,
2007) but sometimes can also be controlled by the person (Kong, Allen, &
Glisky, 2008).
A famous real-life example of dissociative identity disorder is the “three
faces of Eve” case, based on the life of
a woman named Chris Sizemore (Thigpen & Cleckley, 1957) (Figure 12.8).
Eve White was the original dominant
personality. She had no knowledge of her
second personality, Eve Black, although
Eve Black had been alternating with Eve
White for a number of years. Eve White
was bland, quiet, and serious. By contrast, Eve Black was carefree, mischievous, and uninhibited. Eve Black would
emerge at the most inappropriate times,
FIGURE 12.8 The Three Faces of Eve Chris Sizemore, the subject of the leaving Eve White with hangovers, bills,
and a reputation in local bars that she
1950s book and film The Three Faces of Eve, is shown here with a work she painted,
titled Three Faces in One.
could not explain. During treatment, a
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third personality emerged: Jane. More mature than the other two, Jane seems to have
developed as a result of therapy. More recently, former Heisman Trophy winner and
legendary NFL running back Herschel Walker (2008) revealed his experience with
dissociative disorder in his book Breaking Free: My Life with Dissociative Identity
Disorder.
Research on dissociative identity disorder links a high rate of extraordinarily severe
sexual or physical abuse during early childhood to the condition (Ross & Ness, 2010).
Some psychologists believe that a child can cope with intense trauma by dissociating
from the experience and developing other alternate selves as protectors. Sexual abuse has
occurred in as many as 70 percent or more of dissociative identity disorder cases (Foote
& others, 2006); however, the majority of individuals who have been sexually abused do
not develop dissociative identity disorder. The vast majority of individuals with dissociative identity disorder are women. A genetic predisposition might also exist, as the disorder tends to run in families (Dell & Eisenhower, 1990).
Until the 1980s, only about 300 cases of dissociative identity disorder had ever been
reported (Suinn, 1984). In the past 30 years, hundreds more cases have been diagnosed.
Social cognitive approaches point out that diagnoses have tended to increase whenever
the popular media present a case, as in the miniseries Sybil and the Showtime drama
United States of Tara. From this perspective, individuals develop multiple identities
through social contagion. After exposure to these examples, people may be more likely
to view multiple identities as a real condition. Some experts believe, in fact, that dissociative identity disorder is a social construction—that it represents a category some
people adopt to make sense of their experiences (Spanos, 1996). Rather than being
a single person with many conflicting feelings, wishes, and potentially awful
experiences, the individual compartmentalizes different aspects of the self into
independent identities. In some cases, therapists have been accused of creating
alternate personalities. Encountering an individual who appears to have a fragmented sense of self, the therapist may begin to treat each fragment as its own
“personality” (Spiegel, 2006).
Cross-cultural comparisons can shed light on whether dissociative identity disorder is
primarily a response to traumatic events or the result of a social cognitive factor like
social contagion. If dissociation is a response to trauma, individuals with similar levels
of traumatic experience should show similar degrees of dissociation, regardless of their
exposure to cultural messages about dissociation. In China, the popular media do not
commonly portray individuals with dissociative disorder, and professional knowledge of
the disorder is rare. One study comparing individuals from China and Canada (where
dissociative identity disorder is a widely publicized condition) found reports of traumatic
experience to be similar across groups and to relate to dissociative experiences similarly
as well (Ross & others, 2008), casting some doubt on the notion that dissociative experiences are entirely a product of social contagion.
T herapists and patients
are making attributions to
understand abnormal behavior.
1. Dissociative identity disorder is associated with unusually high rates of
A. anxiety.
B. abuse during early childhood.
C. depression.
D. divorce.
2. Someone who suffers memory loss after
a psychological trauma is said to have
A. dissociative identity disorder.
B. dissociative recall disorder.
C. dissociative amnesia.
D. schizophrenia.
3. In cases of dissociative amnesia, the
individual not only experiences amnesia
but also
A. has frequent thoughts of suicide.
B. takes on multiple different
identities.
C. refuses to leave his or her home.
D. travels away from home.
APPLY IT!
4. Eddie often loses track of
time. He is sometimes late for appointments because he is so engrossed in whatever he is doing. While working on a term
paper in the library, he gets so caught up in
what he is reading that he is shocked when
he looks up and sees that the sun has set
and it is night. Which of the following best
describes Eddie?
A. Eddie is showing signs of dissociative
identity disorder.
B. Eddie is showing signs of dissociative
memory disorder.
C. Eddie is showing normal dissociative
states.
D. Eddie is at risk for dissociative amnesia.
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6 Schizophrenia
psychosis
A state in which a person’s
perceptions and thoughts
are fundamentally removed
from reality.
Have you had the experience of watching a movie and suddenly noticing that the film
bears an uncanny resemblance to your life? Have you ever listened to a radio talk show
and realized that the host was saying exactly what you were just thinking? Do these
moments mean something special about you, or are they coincidences? For individuals
with severe psychological disorders, such random experiences feel not random but filled
with meaning. Psychosis refers to a state in which a person’s perceptions and thoughts
are fundamentally removed from reality. DSM-5 recognizes a class of disorders called
Schizophrenia Spectrum and Other Psychotic Disorders. Within this group is one of the
most debilitating psychological disorders (and our focus in this section), schizophrenia.
Schizophrenia is a severe psychological disorder that is characterized by highly disordered thought processes. These disordered thoughts are referred to as psychotic because
they are far removed from reality. The world of the person with schizophrenia is deeply
frightening and chaotic.
Schizophrenia is usually diagnosed in early adulthood, around age 18 for men and
25 for women. Individuals with schizophrenia may see things that are not there, hear
voices inside their heads, and live in a strange world of twisted logic. They may say odd
things, show inappropriate emotion, and move their bodies in peculiar ways. Often,
they are socially withdrawn and isolated.
It is difficult to imagine the ordeal of people living with schizophrenia, who
comprise about half of the patients in psychiatric hospitals. The suicide risk
for individuals with schizophrenia is eight times that for the general population
(Pompili & others, 2007). For many with the disorder, controlling it means
using powerful medications to combat symptoms. The most common cause of
relapse is that individuals stop taking their medication. They might do so because
they feel better and believe they no longer need the drugs, they do not realize that
their thoughts are disordered, or the side effects of the medications are too unpleasant.
Seeking treatment for
schizophrenia takes courage. It
requires that individuals accept
that their perception of the
world—their very sense of
reality—is mistaken.
schizophrenia
Severe psychological disorder
characterized by
highly disordered
thought processes; individuals suffering from
schizophrenia
may be referred
to as psychotic
because they are
so far removed
from reality.
Symptoms of Schizophrenia
Psychologists generally classify the symptoms of schizophrenia as positive symptoms,
negative symptoms, and cognitive deficits (NIMH, 2008).
POSITIVE SYMPTOMS
The positive symptoms of schizophrenia are marked by
a distortion or an excess of normal function. They are “positive” because they reflect
something added above and beyond normal behavior. Positive symptoms of schizophrenia
include hallucinations, delusions, thought disorders, and disorders of movement.
Hallucinations are sensory experiences that occur in the absence of real stimuli.
Hallucinations are usually auditory—the person might complain of hearing voices—or
visual, and much less commonly they can be experienced as smells or tastes (Bhatia &
others, 2009). Culture affects the form hallucinations take, as well as their content and
sensory modality—that is, whether the hallucinations are visual, auditory, or manifest as
smells or tastes (Bauer & others, 2011). Visual hallucinations involve seeing things that
are not there, as in the case of Moe Armstrong. At the age of 21, while serving in Vietnam
as a Marine medical corpsman, Armstrong experienced a psychotic break. Dead Vietcong
soldiers appeared to talk to him and beg him for help and did not seem to realize that they
were dead. Armstrong, now a successful businessman and a sought-after public speaker
who holds two master’s degrees, relies on medication to keep such experiences at bay
(Bonfatti, 2005).
Delusions are false, unusual, and sometimes magical beliefs that are not part of an
individual’s culture. A delusional person might think that he is Jesus Christ or Muhammad;
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hallucinations
Sensory experiences that occur
in the absence of
real stimuli.
delusions
False, unusual,
and sometimes
magical beliefs
that are not part
of an individual’s
culture.
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catatonia
State of immobility and unresponsiveness lasting
for long periods
of time.
flat affect
The display of
little or no
emotion—a
common negative symptom of
schizophrenia.
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another might imagine that her thoughts are being broadcast over the
radio. It is crucial to distinguish delusions from cultural ideas such as
the religious belief that a person can have divine visions or communicate personally with a deity. Generally, psychology and psychiatry do
not treat these ideas as delusional.
For individuals with schizophrenia, delusional beliefs that might
seem completely illogical to the outsider are experienced as all too
real. At one point in his life, Bill Garrett (from the chapter-opening
vignette) was convinced that a blister on his hand was a sign of gangrene. So strong was his belief that he tried to cut off his hand with a
knife, before being stopped by his family (M. Park, 2009).
Thought disorder refers to the unusual, sometimes bizarre thought
processes that are characteristic positive symptoms of schizophrenia.
The thoughts of persons with schizophrenia can be disorganized and
confused. Often individuals with schizophrenia do not make sense
when they talk or write. For example, someone with schizophrenia
might say, “Well, Rocky, babe, happening, but where, when, up, top,
side, over, you know, out of the way, that’s it. Sign off.” These
incoherent, loose word associations, called word salad, have no
meaning for the listener. The individual might also make up new
words (Kerns & others, 1999). In addition, a person with schizophrenia can show referential thinking, which means giving personal meaning to completely random events. For instance, the
individual might believe that a traffic light has turned red because
he or she is in a hurry.
A final type of positive symptom is disorders of movement. A person with schizophrenia may show unusual mannerisms, body movements, and facial expressions. The individual may repeat certain
motions over and over or, in extreme cases, may become catatonic.
Catatonia is a state of immobility and unresponsiveness that lasts for
time (Figure 12.9).
FIGURE 12.9 Disorders of
Movement in Schizophrenia Unusual motor
behaviors are positive symptoms of schizophrenia.
Individuals may cease to move altogether (a state
called catatonia), sometimes holding bizarre
postures.
long periods of
referential thinking
Ascribing personal meaning
to completely random
events.
NEGATIVE SYMPTOMS
Whereas schizophrenia’s positive symptoms are characterized by a distortion or an excess of normal functions, schizophrenia’s negative
symptoms reflect social withdrawal, behavioral deficits, and the loss or decrease
of normal functions. One negative symptom is flat affect, which means the
display of little or no emotion (LePage & others, 2011). Individuals with schizophrenia also may be lacking in the ability to read the emotions of others (Chambon, Baudouin, & Franck, 2006). They may experience a lack of positive
emotional experience in daily life and show a deficient ability to plan, initiate,
and engage in goal-directed behavior.
Because negative
symptoms are not as obviously
part of a psychiatric illness,
people with schizophrenia may be
perceived as lazy and unwilling to
better their lives.
COGNITIVE SYMPTOMS
Cognitive symptoms of schizophrenia include difficulty sustaining attention, problems holding information in memory, and inability to interpret information and make decisions (Sitnikova, Goff, & Kuperberg, 2009; Torniainen &
others, 2012). These symptoms may be subtle and are often detected only through neuropsychological tests. Researchers now recognize that to understand schizophrenia’s cognitive symptoms fully, measures of these symptoms must be tailored to particular cultural
contexts (Mehta & others, 2011).
Causes of Schizophrenia
A great deal of research has investigated schizophrenia’s causes, including biological,
psychological, and sociocultural factors involved in the disorder.
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E XPE RI ENCE IT!
John Nash: A Beautiful
Mind
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BIOLOGICAL FACTORS
Research provides strong support for biological explanations of schizophrenia. Especially compelling is the evidence for a genetic predisposition
(Tao & others, 2012). However, structural abnormalities and neurotransmitters also are
linked to this severe psychological disorder (Perez-Costas & others, 2012; Sugranyes &
others, 2012).
Heredity Research supports the notion that schizophrenia is at least partially due to
genetic factors (Vasco, Cardinale, & Polonia, 2012). As genetic similarity to a person
with schizophrenia increases, so does a person’s risk of developing schizophrenia, as
Figure 12.10 shows (Cardno & Gottesman, 2000). Such data strongly suggest that genetic
factors play a role in schizophrenia. Researchers are seeking to pinpoint the chromosomal
location of genes involved in susceptibility to schizophrenia (Crowley & others, 2012;
van Beveren & others, 2012).
Structural Brain Abnormalities Studies have found structural brain abnormalities in people with schizophrenia. Imaging techniques such as MRI scans clearly show
enlarged ventricles in the brain (Rais & others, 2012). Ventricles are fluid-filled spaces,
and enlargement of the ventricles indicates the deterioration in other brain tissue. Individuals with schizophrenia also have a small frontal cortex (the area in which thinking,
planning, and decision making take place) and show less activity in this area than individuals who do not have schizophrenia (Cotter & others, 2002).
Still, the differences between the brains of healthy individuals and those with schizophrenia are small (NIMH, 2008). Microscopic studies of brain tissue after death reveal
small changes in the distribution or characteristics of brain cells in persons with schizophrenia. It appears that many of these changes occurred prenatally, because they are not
accompanied by glial cells, which are always present when a brain injury occurs after
P SYC H O L O G I CA L I N Q U I RY
FIGURE 12.10 Lifetime Risk
of Developing Schizophrenia
According to Genetic
Relatedness As genetic relatedness to
an individual with schizophrenia increases,
so does the risk of developing schizophrenia.
> Which familial relationships have
the lowest and highest level of genetic
overlap? > What is the difference in
genetic overlap between identical twins
and non-twin siblings? > What is the
difference in risk of schizophrenia
between identical twins and
non-twin siblings?
Relationship to Person with Schizophrenia
1%
General population
Genes shared
First cousins
2%
Uncles/aunts
2%
12.5% 3rd degree relatives
25% 2nd degree relatives
50% 1st degree relatives
100%
4%
Nephews/nieces
5%
Grandchildren
Half siblings
6%
Parents
6%
9%
Siblings
13%
Children
17%
Fraternal twins
48%
Identical twins
0
5
10
15
20
25
30
35
40
Percentage Risk of Developing Schizophrenia
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50
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birth. It may be that problems in prenatal development such as infections (A. S. Brown,
2006) predispose a brain to developing schizophrenic symptoms during puberty and
young adulthood (Fatemi & Folsom, 2009).
Problems in Neurotransmitter Regulation
An early biological explanation for
schizophrenia linked excess dopamine production to schizophrenia. The link between dopamine and psychotic symptoms was first noticed when the drug L-dopa (which increases
dopamine levels) was given to individuals as a treatment for Parkinson disease. In addition
to relieving their Parkinson symptoms, L-dopa caused some individuals to experience disturbed thoughts (Janowsky, Addario, & Risch, 1987). Furthermore, drugs that reduce psychotic symptoms often block dopamine (Kapur, 2003). Whether it is differences in the
amount, the production, or the uptake of dopamine, there is good evidence that dopamine
plays a role in schizophrenia (Brito-Melo & others, 2012; Howes & others, 2012).
As noted in the chapters about states of consciousness (Chapter 4) and learning
(Chapter 5), dopamine is a “feel good” neurotransmitter that helps us recognize
rewarding stimuli in the environment. As described in the chapter on personality
(Chapter 10), dopamine is related to being outgoing and sociable. How can a neurotransmitter that is associated with good things play a crucial role in the most devastating psychological disorder?
One way to think about this puzzle is to view dopamine as a neurochemical messenger that in effect shouts out, “Hey! This is important!” whenever we encounter opportunities for reward. Imagine what it might be like to be bombarded with such messages
about even the smallest details of life (Kapur, 2003). The person’s own thoughts might
take on such dramatic proportions that they sound like someone else’s voice talking
inside the person’s head. Fleeting ideas such as “It’s raining today because I didn’t bring
my umbrella to work” suddenly seem not silly but true. Shitij Kapur (2003) has suggested
that hallucinations, delusions, and referential thinking may be expressions of the individual’s attempts to make sense of such extraordinary feelings.
A problem with the dopamine explanation of schizophrenia is that antipsychotic drugs
reduce dopamine levels very quickly, but delusional beliefs take much longer to disappear.
Even after dopamine levels are balanced, a person might still cling
to the bizarre belief that members of a powerful conspiracy are
watching his every move. If dopamine causes these symptoms,
why do the symptoms persist even after the dopamine is under
control? According to Kapur, delusions serve as explanatory
schemes that have helped the person make sense of the random
and chaotic experiences caused by out-of-control dopamine.
Bizarre beliefs might disappear only after experience demonstrates
that such schemes no longer carry their explanatory power (Kapur,
2003). That is, with time, experience, and therapy, the person
might come to realize that there is, in fact, no conspiracy.
Excess dopamine basically
tells the person that
everything is important.
PSYCHOLOGICAL FACTORS
diathesis-stress
model
View of schizophrenia emphasizing that a
combination of
biogenetic disposition and
stress causes
the disorder.
Psychologists used to explain schizophrenia as
rooted in an individual’s difficult childhood experiences with parents. Such explanations
have mostly fallen by the wayside, but contemporary theorists do recognize that stress
may contribute to the development of this disorder. The diathesis-stress model
argues that a combination of biogenetic disposition and stress causes schizophrenia
(Meehl, 1962). (Diathesis means “physical vulnerability or predisposition to a particular disorder.”) For instance, genetic characteristics might produce schizophrenia
only when (and if ) the individual experiences extreme stress.
Recall that Moe
Armstrong experienced
his first symptoms during the
extremely stressful experience
of the Vietnam War.
SOCIOCULTURAL FACTORS
A fascinating finding on sociocultural factors in
schizophrenia is a consistent difference in the course of schizophrenia over time in developing versus developed nations. Specifically, individuals with schizophrenia in developing, nonindustrialized nations are more likely to show indications of recovery over time
compared to those in developed, industrialized nations (Bhugra, 2006; Jablensky, 2000;
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Myers, 2010). Whether measured in symptoms, disturbances in thought, or the ability to
engage in productive work, individuals in less developed countries appear to do better
than their counterparts in developed nations.
This difference is puzzling. Some experts argue that developing nations must be misdiagnosing more individuals or are better off than the label “developing” implies (Burns,
2009). Other commentators look to differences in cultural beliefs and practices to understand
these effects. For instance, it might be that in more developed nations (such as the United
States), there is not a very strong belief that individuals diagnosed with schizophrenia can
recover (Luhrmann, 2007). In addition, cultures vary in terms of their beliefs about and
responses to symptoms. In Chandigarh, India, for example, where some of the developingnation data were collected, visual hallucinations were not viewed as very different from
commonplace religious experiences (Luhrmann, 2007). Moreover, in developing
nations, families remained involved in individuals’ lives after diagnosis, and many
families lived in close-knit communities where care of their loved one was not
so burdensome (Hopper & Wanderling, 2000). The fact that culture matters to
schizophrenia highlights the role of cultural context in psychological disorders. Consider that even if individuals with schizophrenia were found to
share some common brain characteristics, these similar brains would have
different experiences and different outcomes as a result of culture.
If you have never met anyone with
In developed nations, schizophrenia is strongly associated with povschizophrenia, why not get to know
erty, but it is not clear if poverty increases the likelihood of experiencing
Moe Armstrong online? Search for
the disorder (Luhrmann, 2007). Marriage, warm and supportive friends
clips of one of Moe’s many
(Jablensky
& others, 1992; Wiersma & others, 1998), and employment are
speeches on YouTube.
related to better outcomes for people diagnosed with schizophrenia (Rosen
& Garety, 2005). At the very least, this research suggests that some individuals with schizophrenia enjoy marriage, productive work, and friendships (Drake,
Levine, & Laska, 2007; Fleischhaker & others, 2005; Marshall & Rathbone, 2006).
1. A negative symptom of schizophrenia is
A. hallucinations.
B. flat affect.
C. delusions.
D. catatonia.
2. Joel believes that he has superhuman
powers. He is likely suffering from
A. hallucinations.
B. delusions.
C. negative symptoms.
D. referential thinking.
3. The biological causes of schizophrenia
include
A. problems with the body’s regulation
of dopamine.
B. abnormalities in brain structure such
as enlarged ventricles and a small
frontal cortex.
C. both A and B
D. neither A nor B
APPLY IT!
4. During a psychiatric hospital internship, Tara approaches a young
man sitting alone in a corner, and they
have a short conversation. He asks her if
she is with the government, and she tells
him that she is not. She asks him a few
questions and walks away. She tells her
advisor later that what disturbed her about
the conversation was not so much what the
young man said, but that she had this feeling that he just was not really there. Tara
was noticing the _________ symptoms of
schizophrenia.
A. positive
B. negative
C. cognitive
D. genetic
7 Personality Disorders
personality disorders
Chronic, maladaptive
cognitive-behavioral
patterns that are thoroughly
integrated into an
individual’s personality.
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Imagine that your personality—the very thing about you that makes you you—is the core
of your life difficulties. That is what happens with personality disorders, which are
chronic, maladaptive cognitive-behavioral patterns that are thoroughly integrated into an
individual’s personality. Personality disorders are relatively common. In one study of a
representative U.S. sample, researchers found that 15 percent had a personality disorder
(Grant & others, 2004).
With respect to DSM-5, the revisions for personality disorders were among the most
highly anticipated. The biggest proposed change involved moving to an understanding of
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personality disorders within the context of the five-factor model of personality traits (see
Chapter 10). Using the five factors to explain personality disorders is called the dimensional
approach. From this perspective, personality disorders can be understood not as categories
but as variants or extreme cases of the kinds of traits we see in healthy people. Many scholars looked forward to the integration of a dimensional approach to personality disorders
(Krueger & Eaton, 2010; Miller & others, 2012; Trull, Carpenter, & Widiger, 2013; Widiger,
2011; Widiger & Costa, 2013). Some research supported the idea that approaching personality disorders from a trait perspective would lead to better diagnoses (Yalch, Thomas, &
Hopwood, 2012). Other research, however, suggested that the change was unnecessary
(Zimmerman & others, 2011; Morgan & others, 2013) and would be less useful to clinicians
(Rottman & others, 2011). In the end, the proposed changes were not adopted. DSM-5 lists
the same 10 personality disorders as previous editions (see Figure 12.11).
In this section we survey the two personality disorders that have been the object of
most study: antisocial personality disorder and borderline personality disorder. Both are
associated with dire consequences. Specifically, antisocial personality disorder is linked
to criminal activity and violence; borderline personality disorder, to self-harm and suicide.
Antisocial Personality Disorder
Antisocial personality disorder (ASPD) is a psychological disorder characterized by
guiltlessness, law-breaking, exploitation of others, irresponsibility, and deceit. Although
antisocial personality
disorder (ASPD)
Psychological disorder characterized by guiltlessness,
law-breaking, exploitation
of others, irresponsibility,
and deceit.
Personality Disorder
Description
Paranoid Personality Disorder
Paranoia, suspiciousness, and deep distrust of others. People with this disorder are always on the lookout
for danger and the slightest social mistreatment. They may be socially isolated.
Schizoid Personality Disorder
Extreme lack of interest in interpersonal relationships. People with this disorder are emotionally cold and
apathetic, and they are generally detached from interpersonal life.
Schizotypal Personality Disorder
Socially isolated and prone to odd thinking. People with this disorder often have elaborate and strange
belief systems and attribute unusual meanings to life events and experiences.
Antisocial Personality Disorder
Manipulative, deceitful, and amoral. People with this disorder lack empathy for others, are egocentric,
and are willing to use others for their own personal gain.
Borderline Personality Disorder
Emotionally volatile and unstable sense of self. These individuals are prone to mood swings, excessive
self-criticism, extreme judgments of others, and are preoccupied with being abandoned.
Histrionic Personality Disorder
Attention-seeking, dramatic, lively, and flirtatious. These individuals are inappropriately seductive in their
interactions with others.
Narcissistic Personality Disorder
Self-aggrandizing yet overly dependent on the evaluations of others. People with this disorder view
themselves as entitled and better than others. They show deficits in empathy and in understanding the
feelings of others.
Avoidant Personality Disorder
Socially inhibited and prone to feelings of inadequacy, anxiety, and shame. These individuals feel
inadequate and hold back in social situations. They have unrealistic standards for their own behavior and
avoid setting goals, taking personal risks, or pursuing new activities.
Dependent Personality Disorder
Dependent on others for emotional and physical needs. People with this disorder perceive others as
powerful and competent and themselves as childlike and helpless.
Obsessive-Compulsive Personality
Disorder
Conforming rigidly to rules. These individuals show an excessive attachment to moral codes and are
excessively orderly in daily life.
FIGURE 12.11 The 10 Personality Disorders Included in DSM-5. Diagnoses of these disorders require that the person be over the age of
18, and all involve pervasive aspects of the person that color cognition, emotion, and behavior. Note that some of the labels are potentially confusing. Schizoid and
schizotypal personality disorders are not the same thing as schizophrenia (though schizotypal personality disorder may proceed to schizophrenia). Further, obsessivecompulsive personality disorder is not the same thing as obsessive-compulsive disorder.
Pers onality Dis orders
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they may be superficially charming, individuals with ASPD do not play by the rules, and
they often lead a life of crime and violence. ASPD is far more common in men than in
women and is related to criminal behavior, vandalism, substance abuse, and alcoholism
(Cale & Lilienfeld, 2002).
ASPD is characterized by:
■
■
■
■
■
■
■
Failure to conform to social norms or obey the law
Deceitfulness, lying, using aliases, or conning others for personal profit or pleasure
Impulsivity
Irritability and aggressiveness; getting into physical fights or perpetrating assaults
Reckless disregard for the safety of self or others
Consistent irresponsibility, inconsistent work behavior; not paying bills
Lack of remorse, indifference to the pain of others, or rationalizing; hurting or mistreating another person
Generally, ASPD is not diagnosed unless a person has shown persistent antisocial behavior before the age of 15.
Although ASPD is associated with criminal behavior, not all individuals with ASPD
engage in crime, and not all criminals suffer from ASPD. Some individuals with ASPD can
have successful careers. There are antisocial physicians, clergy members, lawyers, and just
about any other occupation. Still, such individuals tend to be exploitative of others, and they break the rules, even if they are never caught.
What is the etiology of ASPD? Biological factors include genetic,
brain, and autonomic nervous system differences. We consider these
in turn.
ASPD is genetically heritable (Nordstrom & others, 2012). Certain
genetic characteristics associated with ASPD may interact with testosterone (the hormone most associated with aggressive behavior) to
promote antisocial behavior (Sjoberg & others, 2008). Although the
experience of childhood abuse may be implicated in ASPD, there is
evidence that genetic differences may distinguish abused children
who go on to commit violent acts themselves from those who do
not (Caspi & others, 2002).
In terms of the brain, research has linked ASPD to low levels
of activation in the prefrontal cortex and has related these brain
differences to poor decision making and problems in learning
(Raine & others, 2000). With regard to the autonomic nervous system, researchers have found that individuals with
ASPD are less stressed than others by aversive circumstances,
including punishment (Fung & others, 2005), and that they
have the ability to keep their cool while engaging in deception
(Verschuere & others, 2005). The underaroused autonomic nervous
system may be a key difference between adolescents who become
antisocial adults and those whose behavior improves during adulthood (Raine, Venables, & Williams, 1990).
The term psychopath is sometimes used to refer to a subgroup
of individuals with ASPD (Pham, 2012). Psychopaths are remorseless predators who engage in violence to get what they want.
Examples of psychopaths include serial killers John Wayne Gacy,
who murdered 33 boys and young men, and Ted Bundy, who
confessed to murdering at least 30 young women. Psychopaths John Wayne Gacy (top) and Ted Bundy
tend to show less prefrontal activation than normal individuals and (bottom) exemplify the subgroup of
to have structural abnormalities in the amygdala, as well as the people with ASPD who are also
hippocampus, the brain structure most closely associated with psychopathic.
Lack of autonomic
nervous system activity
suggests why individuals with
ASPD might be able to fool a
polygraph (lie detector).
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memory (Weber & others, 2008). Importantly, these brain differences are most pronounced in “unsuccessful psychopaths”—individuals who have been arrested for
their behaviors (Yang & others, 2005). In contrast, “successful psychopaths”—
individuals who have engaged in antisocial behavior but have not gotten caught—
are more similar to healthy controls in terms of brain structure and function.
However, in their behavior, successful psychopaths demonstrate a lack of empathy
and a willingness to act immorally; they victimize others to enrich their own lives.
Psychopaths show deficiencies in learning about fear and have difficulty processing
information related to the distress of others, such as sad or fearful faces (Dolan &
Fullam, 2006).
A key challenge in treating individuals with ASPD, including psychopaths, is their
ability to con even sophisticated mental health professionals. Many never seek therapy,
and others end up in prison, where treatment is rarely an option.
T heir functioning
frontal lobes might help
successful psychopaths
avoid getting caught.
Borderline Personality Disorder
Borderline personality disorder (BPD) is a pervasive pattern of instability in interpersonal relationships, self-image, and emotions, and of marked impulsivity beginning by
early adulthood and present in various contexts. Individuals with BPD are insecure,
impulsive, and emotional (Hooley, Cole, & Gironde, 2012). BPD is related to self-harming
behaviors such as cutting (injuring oneself with a sharp object but without suicidal intent)
and also to suicide (Soloff & others, 1994).
At the very core of BPD is profound instability in mood, in sense of self, and in relationships. BPD is characterized by four essential features (Trull & Brown, 2013):
■
■
■
■
Unstable affect
Unstable sense of self and identity, including self-destructive impulsive behavior and
chronic feelings of emptiness
Negative interpersonal relationships that are unstable, intense, and characterized by
extreme shifts between idealization and devaluation
Self-harm, including recurrent suicidal behavior, gestures, or threats or self-mutilating
behavior.
borderline personality
disorder (BPD)
Psychological disorder
characterized by a pervasive
pattern of instability in interpersonal relationships, selfimage, and emotions, and
of marked impulsivity beginning by early adulthood and
present in a variety of
contexts.
E X PE R I E N C E I T !
Borderline Personality
Disorder
Individuals with BPD are prone to wild mood swings and very sensitive to how
others treat them. They often feel as if they are riding a nonstop emotional rollercoaster (Selby & others, 2009), and their loved ones may have to work hard to avoid
upsetting them. Individuals with BPD tend to see the world in black-and-white
terms, a thinking style called splitting. For example, they typically view other
people as either hated enemies with no positive qualities or as beloved, idealized friends who can do no wrong.
Borderline personality disorder is far more common in women than men.
Women make up 75 percent of those with the disorder (Korzekwa & others,
2008; Oltmanns & Powers, 2012).
The potential causes of BPD are likely complex and include biological factors as well as childhood experiences. The role of genes in BPD has been
demonstrated in a variety of studies and across cultures (Mulder, 2012). The
heritability of BPD is about 40 percent (Distel & others, 2008).
Many individuals with borderline personality disorder report experiences of childhood sexual abuse, as well as physical abuse and neglect (Al-Alem & Omar, 2008; De
Fruyt & De Clercq, 2012). It is not clear, however, whether abuse is a primary cause of
the disorder (Trull & Widiger, 2003). Childhood abuse experiences may combine
with genetic factors in promoting BPD.
Cognitive factors associated with BPD include a tendency to hold a set of
irrational beliefs (Leahy & McGinn, 2012). These include thinking that one
Movie depictions of BPD
include Fatal Attraction,
Single White Female, and
Obsessed. Where these films
get it wrong is that they show
BPD as leading to more harm to
others than to the self.
T his would be a diathesisstress model explanation for BPD.
Pers onality Dis orders
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is powerless and innately unacceptable and that other people are dangerous and hostile
(Arntz, 2005). Individuals with BPD also display hypervigilance: the tendency to
be constantly on the alert, looking for threatening information in the environment
(Sieswerda & others, 2007).
Up until 20 years ago, experts thought that BPD was untreatable. More
recent evidence, however, suggests that many individuals with BPD show
improvement over time—as many as 50 percent within two years of starting
treatment (Gunderson, 2008). One key aspect of successful treatment appears
to be a reduction in social stress, such as that due to leaving an abusive
romantic partner or establishing a sense of trust in a therapist (Gunderson &
others, 2003).
To recognize the severe
toll of BPD on those suffering
from it (and on their families and
friends), in 2008 the U.S. House
of Representatives declared May
to be National Borderline
P ersonality Disorder
Awareness Month.
1. Individuals with ASPD
A. are incapable of having successful
careers.
B. are typically women.
C. are typically men.
D. rarely engage in criminal behavior.
2. People with BPD
A. pay little attention to how others
treat them.
B. rarely have problems with anger or
strong emotion.
C. tend to have suicidal thoughts or
engage in self-harming actions.
D. tend to have a balanced viewpoint of
people and things rather than to see
them as all black or all white.
3. All of the following are true of BPD except
A. BPD can be caused by a combination
of nature and nurture—genetic inheritance and childhood experience.
B. Recent research has shown that people with BPD respond positively to
treatment.
C. A common symptom of BPD is impulsive behavior such as binge eating
and reckless driving.
D. BPD is far more common in men than
women.
APPLY IT!
4. Your new friend Maureen
tells you that she was diagnosed with borderline personality disorder at the age of
23. She feels hopeless when she considers
that her mood swings and unstable selfesteem are part of her very personality.
Despairing, she asks, “How will I ever
change?” Which of the following statements
about Maureen’s condition is accurate?
A. Maureen should seek therapy and strive
to improve her relationships with others,
as BPD is treatable.
B. Maureen’s concerns are realistic, because
a personality disorder like BPD is
unlikely to change.
C. Maureen should seek treatment for BPD
because there is a high likelihood that
she will end up committing a criminal act.
D. Maureen is right to be concerned,
because BPD is most often caused by
genetic factors.
8 Combatting Stigma
Putting a label on a person with a psychological disorder can make the disorder seem
like something that happens only to other people (Baumann, 2007). The truth is that
psychological disorders are not just about other people; they are about people, period.
Over 26 percent of Americans ages 18 and older suffer from a diagnosable psychological disorder in a given year—an estimated 57.7 million U.S. adults (Kessler & others,
2005; NIMH, 2008). Chances are that you or someone you know will experience a
psychological disorder. Figure 12.12 shows how common many psychological disorders
are in the United States.
A classic and controversial study illustrates that labels of psychological disorder can
be “sticky”—hard to remove once they are applied to a person. David Rosenhan (1973)
recruited eight adults (including a stay-at-home mother, a psychology graduate student,
a pediatrician, and some psychiatrists), none with a psychological disorder, to see a
psychiatrist at various hospitals. These “pseudo-patients” were instructed to act normally
except to complain about hearing voices that said things like “empty” and “thud.” All
eight expressed an interest in leaving the hospital and behaved cooperatively. Nevertheless, all eight were labeled with schizophrenia and kept in the hospital from 3 to 52 days.
None of the mental health professionals they encountered ever questioned the diagnosis
that was given to these individuals, and all were discharged with the label “schizophrenia in remission.” The label “schizophrenia” had stuck to the pseudo-patients and caused
the professionals around them to interpret their quite normal behavior as abnormal.
Clearly, once a person has been labeled with a psychological disorder, that label colors
how others perceive everything else he or she does.
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Labels of psychological disorder carry
with them a wide array of implications for
the individual. Is the person still able to be
a good friend? A good parent? A competent
worker? A significant concern for individuals
with psychological disorders is the negative
attitudes that others might have about people
struggling with mental illness (Phelan &
Basow, 2007). Stigma can be a barrier for
individuals coping with a psychological disorder, as well as for their families and loved
ones (Corrigan, 2007; Hinshaw, 2007). Negative attitudes about individuals with psychological disorders are common in many
cultures, and cultural norms and values influence these attitudes (Abdullah & Brown,
2011). Fear of stigma can prevent individuals
from seeking treatment and from talking about
their problems with family and friends.
Consequences
of Stigma
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Anxiety Disorders
General anxiety disorder
Panic disorder
Specific phobia
PTSD
Major Depressive Disorder
Bipolar Disorder
Schizophrenia
Number of
U.S. Adults in a
Given Year (Millions)
Percentage
of U.S. Adults
6.8
6.0
19.2
7.7
14.8
5.7
2.4
3.1%
2.7%
8.7%
3.5%
6.7%
2.6%
1.1%
FIGURE 12.12 The 12-Month Prevalence of the Most
Common Psychological Disorders If you add up the numbers in this
figure, you will see that the totals are higher than the numbers given in the text.
The explanation is that people are frequently diagnosed with more than one
psychological disorder. An individual who has both a depressive and an anxiety
disorder would be counted in both of those categories.
The stigma attached to psychological disorders can provoke prejudice and discrimination
toward individuals who are struggling with these problems, thus complicating an already
difficult situation. Having a disorder and experiencing the stigma associated with it can
also negatively affect the physical health of such individuals.
PREJUDICE AND DISCRIMINATION
Labels of psychological disorders can be
damaging because they may lead to negative stereotypes, which play a role in prejudice.
For example, the label “schizophrenic” often has negative connotations such as “frightening”
and “dangerous.”
Vivid cases of extremely harmful behavior by individuals with psychological disorders can perpetuate the stereotype that people with such disorders are violent. For
example, Cho Seung-Hui, a 23-year-old college student, murdered 32 students and
faculty at Virginia Tech University in April 2007 before killing himself. The widely
reported fact that Cho had struggled with psychological disorders throughout his life
may have reinforced the notion that individuals with disorders are dangerous. In fact,
however, people with psychological disorders (especially those in treatment) are no
more likely to commit violent acts than the general population. Cho was no more
representative of people with psychological disorders than he was representative of
students at Virginia Tech.
Individuals with psychological disorders are often aware of the negative stigma attached
to these conditions and may themselves have previously held such negative attitudes.
Seeking the assistance they need may involve accepting a stigmatized identity (Thornicroft
& others, 2009; Yen & others, 2009). Even mental health professionals can fall prey to
prejudicial attitudes toward those who are coping with psychological disorders (Nordt,
Rossler, & Lauber, 2006). Improved knowledge about the neurobiological and genetic
processes involved in many psychological disorders appears to be a promising direction
for interventions to reduce such prejudice. Research shows that information about the role
of genes in these disorders reduces prejudicial attitudes (WonPat-Borja & others, 2012).
Among the most feared aspects of stigma is discrimination, or acting prejudicially
toward a person who is a member of a stigmatized group. In the workplace, discrimination
against a person with a psychological disorder violates the law. The Americans with
Combatting Stigma
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Disabilities Act (ADA) of 1990 made it illegal to refuse employment or a promotion to
someone with a psychological disorder when the person’s condition does not prevent
performance of the job’s essential functions (Cleveland, Barnes-Farrell, & Ratz, 1997).
A person’s appearance or behavior may be unusual or irritating, but as long as that
individual is able to complete the duties required of a position, employment or promotion
cannot be denied.
PHYSICAL HEALTH
Individuals with psychological disorders are more likely to
be physically ill and two times more likely to die than their psychologically healthy
counterparts (Gittelman, 2008; Kumar, 2004). They are also more likely to be obese, to
smoke, to drink excessively, and to lead sedentary lives (Kim & others, 2007; Lindwall
& others, 2007; Mykletun & others, 2007; Osborn, Nazareth, & King, 2006).
You might be thinking that these physical health issues are the least of their worries.
If people struggling with schizophrenia want to smoke, why not let them? This type of
thinking sells short the capacity of psychological and psychiatric treatments to help those
with psychological disorders. Research has shown that health-promotion programs can
work well for individuals with a severe psychological disorder (Addington & others,
1998; Chafetz & others, 2008). When we disregard the potential of physical health interventions for people with psychological disorders to make positive life changes, we reveal
our biases.
Overcoming Stigma
How can we combat the stigma of psychological disorders? One obstacle to changing
people’s attitudes toward individuals with psychological disorders is that mental illness
is often “invisible.” That is, sometimes a person we know can have a disorder without
our being aware. We may be unaware of many good lives around us that are being lived
under a cloud of psychological disorder, because worries about being stigmatized keep
the affected individuals from “coming out.” Thus, stigma leads to a catch-22: Positive
examples of individuals coping with psychological disorders are often missing from our
experience because those who are doing well shun public disclosure of their disorders
(Jensen & Wadkins, 2007).
A critical step toward eliminating stigma is to resist thinking of people with disorders
as limited by their condition. Instead, it is vital to recognize their strengths—both in
confronting their disorder and in carrying on despite their problems—and their achievements. By creating a positive environment for people with disorders, we encourage more
of them to become confidently “visible” and empower them to be positive role models.
When Milton Greek arrived at Ohio University in the 1980s as a young undergraduate, he had an ambitious goal: “to discover a psychological code that people should live
by, to create world peace” (Carey, 2011a). He became known as a person with very
strange ideas. By his senior year, Milt was in a failing marriage and was convinced that
he had met God one day on the street and Jesus a few days later. Although he was a
lifelong atheist, his delusions took on a distinctive religious character. He believed the
Rapture would occur at any moment and that he himself was the anti-Christ. He heard
voices no one else did and saw things that were not there. Eventually diagnosed with
schizophrenia, Milt began taking medication and started to put his life back together.
While in graduate school, he stopped taking his medications when things seemed to be
going well, only to have a close friend give him a reality check. “When she used the
word ‘hallucination’ I knew it was true,” he said (Carey, 2011a).
Today Milt is a 49-year-old, happily married computer programmer. He takes medications to control his symptoms and seems again to have found a mission in life. This time
it is about making a difference in the lives of others by sharing his story as a man with
schizophrenia. Along with a small group of other people with serious psychiatric disorders, Milt has “come out” and related his experiences to combat stigma, providing hope
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for others who are suffering with psychological disorders and helping psychologists who
are interested in experiences like his.
After reading this chapter, you know that many admired individuals have dealt with
psychological disorders. Their diagnoses do not detract from their accomplishments. To
the contrary, their accomplishments are all the more remarkable in the context of the
challenges they have faced.
1. The percentage of Americans 18 years of
age and older who suffer from a diagnosable psychological disorder in a
given year is closest to
A. 15 percent.
B. 26 percent.
C. 40 percent.
D. 46 percent.
2. The stigma attached to psychological
disorders can have implications for
A. the physical health of an individual
with such a disorder.
B. the psychological well-being of an
individual with such a disorder.
C. other people’s attitudes and behaviors toward the individual with such
a disorder.
D. all of the above
3. Labeling psychological disorders can
lead to damaging
A. stereotyping.
B. discrimination.
C. prejudice.
D. all of the above
APPLY IT!
4. Liliana has applied for a
job after graduation doing data entry for a
polling firm. During her second interview,
Liliana asks the human resources manager
whether the job’s health benefits include
prescription drug coverage, as she is on
anti-anxiety medication for generalized
anxiety disorder. Which of the following
statements is most applicable, legally and
otherwise, in light of Liliana’s request?
A. The human resources manager should
tell the hiring committee to avoid hiring
Liliana because she has a psychological
disorder.
B. It is illegal for the firm to deny Liliana
employment simply because she has a
psychological disorder.
C. Liliana should not have asked that question, because she will not be hired.
D. Liliana must be given the job, or the
firm could face a lawsuit.
SUMMARY
1 Defining and Explaining
Abnormal Behavior
Abnormal behavior is deviant, maladaptive, or personally distressful.
Theoretical perspectives on the causes of psychological disorders include
biological, psychological, sociocultural, and biopsychosocial approaches.
Biological approaches to disorders describe psychological disorders
as diseases with origins in structural, biochemical, and genetic factors.
Psychological approaches include the behavioral, social cognitive, and
trait perspectives. Sociocultural approaches place emphasis on the larger
social context in which a person lives, including marriage, socioeconomic status, ethnicity, gender, and culture. Biopsychosocial approaches
view the interactions among biological, psychological, and social factors
as significant forces in producing both normal and abnormal behavior.
The classification of disorders provides a shorthand for communication, allows clinicians to make predictions about disorders, and helps them
to decide on appropriate treatment. The Diagnostic and Statistical Manual
of Mental Disorders (DSM) is the classification system clinicians use to diagnose psychological disorders. Some psychologists contend that the DSM
perpetuates the medical model of psychological disorders, labels everyday
problems as psychological disorders, and fails to address strengths.
2 Anxiety and Anxiety-Related
Disorders
Anxiety disorders are characterized by unrealistic and debilitatingly
high levels of anxiety. Generalized anxiety disorder involves a high
level of anxiety with no specific reason for the anxiety. Panic disorder
involves attacks marked by the sudden onset of intense terror.
Specific phobias entail an irrational, overwhelming fear of a particular object, such as snakes, or a situation, such as flying. Social anxiety
disorder refers to the intense fear that one will do something embarrassing or humiliating in public. Obsessive-compulsive disorder involves
anxiety-provoking thoughts that will not go away (obsession) and/or
urges to perform repetitive, ritualistic behaviors to prevent or produce
some future situation (compulsion). Post-traumatic stress disorder
(PTSD) is a disorder that develops through exposure to traumatic
events. Symptoms include flashbacks, emotional avoidance, emotional
numbing, and excessive arousal. A variety of experiential, psychological, and genetic factors have been shown to relate to these disorders.
3 Disorders Involving Emotion
and Mood
In depressive disorders, the individual experiences a serious depressive
episode and depressed characteristics such as lethargy and hopelessness.
Biological explanations of depressive disorders focus on heredity, neurophysiological abnormalities, and neurotransmitter deregulation. Psychological explanations include behavioral and cognitive perspectives.
Sociocultural explanations emphasize socioeconomic and ethnic factors,
as well as gender.
Bipolar disorder is characterized by extreme mood swings that
include one or more episodes of mania (an overexcited, unrealistic,
optimistic state). Most individuals with bipolar disorder go through
multiple cycles of depression interspersed with mania. Genetic
Summary
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influences are stronger predictors of bipolar disorder than depressive
disorder, and biological processes are also a factor in bipolar disorder.
Severe depression and other psychological disorders can cause individuals to want to end their lives. Theorists have proposed biological,
psychological, and sociocultural explanations of suicide.
factors (diathesis-stress model), and sociocultural factors may be involved
in schizophrenia. Psychological and sociocultural factors are not viewed
as stand-alone causes of schizophrenia, but they are related to the course
of the disorder.
7 Personality Disorders
4 Eating Disorders
Anorexia nervosa is characterized by extreme underweight and starvation. The disorder is related to perfectionism and obsessive-compulsive
tendencies. Bulimia nervosa involves a pattern of binge eating followed
by purging through self-induced vomiting. In contrast, binge eating disorder involves binge eating without purging.
Anorexia nervosa and bulimia nervosa are much more common in
women than men, but there is no gender difference in binge-eating
disorder. Although sociocultural factors were once primary in explaining
eating disorders, newer evidence points to the role of biological factors.
5 Dissociative Disorders
Dissociative amnesia involves memory loss caused by extensive
psychological stress. In dissociative identity disorder, formerly
called multiple personality disorder, two or more distinct personalities are present in the same individual; this disorder is rare.
Personality disorders are chronic, maladaptive cognitive-behavioral patterns that are thoroughly integrated into an individual’s personality. Two
common types are antisocial personality disorder (ASPD) and borderline personality disorder (BPD).
Antisocial personality disorder is characterized by guiltlessness, lawbreaking, exploitation of others, irresponsibility, and deceit. Individuals
with this disorder often lead a life of crime and violence. Psychopaths—
remorseless predators who engage in violence to get what they want—
are a subgroup of individuals with ASPD.
Borderline personality disorder is a pervasive pattern of instability in
interpersonal relationships, self-image, and emotions. This disorder is
related to self-harming behaviors such as cutting and suicide.
Biological factors for ASPD include genetic, brain, and autonomic
nervous system differences. The potential causes of BPD are complex
and include biological and cognitive factors as well as childhood
experiences.
8 Combatting Stigma
6 Schizophrenia
Schizophrenia is a severe psychological disorder characterized by
highly disordered thought processes. Positive symptoms of schizophrenia are behaviors and experiences that are present in individuals with
schizophrenia but absent in healthy people; they include hallucinations,
delusions, thought disorder, and disorders of movement. Negative
symptoms of schizophrenia are behaviors and experiences that are part
of healthy human life that are absent for those with this disorder; they
include flat affect and an inability to plan or engage in goal-directed
behavior.
Biological factors (heredity, structural brain abnormalities, and problems in neurotransmitter regulation, especially dopamine), psychological
Stigma can create a significant barrier for people coping with a psychological disorder, as well as for their loved ones. Fear of being labeled can prevent individuals with a disorder from getting treatment
and from talking about their problems with family and friends. In addition, the stigma attached to psychological disorders can lead to
prejudice and discrimination toward individuals who are struggling
with these problems. Having a disorder and experiencing the stigma
associated with it can also negatively affect the physical health of
such individuals. We can help to combat stigma by acknowledging
the strengths and the achievements of individuals coping with psychological disorders.
KEY TERMS
social anxiety disorder, p. 450
obsessive-compulsive disorder
(OCD), p. 451
post-traumatic stress disorder
(PTSD), p. 452
depressive disorders, p. 454
major depressive disorder
(MDD), p. 455
bipolar disorder, p. 457
anorexia nervosa, p. 462
abnormal behavior, p. 441
medical model, p. 443
DSM-5, p. 444
attention deficit hyperactivity
disorder (ADHD), p. 445
anxiety disorders, p. 447
generalized anxiety
disorder, p. 447
panic disorder, p. 448
specific phobia, p. 449
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P s y c h o l o g ica l D iso rders
bulimia nervosa, p. 462
binge-eating disorder (BED), p. 464
dissociative disorders, p. 465
dissociative amnesia, p. 466
dissociative identity disorder
(DID), p. 466
psychosis, p. 468
schizophrenia, p. 468
hallucinations, p. 468
delusions, p. 468
referential thinking, p. 469
catatonia, p. 469
flat affect, p. 469
diathesis-stress model, p. 471
personality disorders, p. 472
antisocial personality disorder
(ASPD), p. 473
borderline personality disorder
(BPD), p. 475
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S E L F -T E S T
Multiple Choice
1. The name for a mark of shame that may
cause people to avoid, or act negatively
toward, an individual is
A. disfigurement.
B. mortification.
C. stigma.
D. prejudice.
2. Feeling an overwhelming sense of dread
and worry without a specific cause is
known as
A. obsessive-compulsive disorder.
B. generalized anxiety disorder.
C. social anxiety disorder.
D. panic disorder.
3. A characteristic of post-traumatic stress
disorder is
A. panic attacks.
B. an exaggerated startle response.
C. persistent nervousness about a variety
of things.
D. extreme fear of an object or place.
4. All of the following are disorders involving
emotion or mood except
A. generalized anxiety disorder.
B. disruptive mood dysregulation disorder.
C. major depressive disorder.
D. bipolar disorder.
5. The diagnostic criteria for major depressive
disorder include the standard that a
depressive episode must last at least
A. one week.
B. two weeks.
C. two months.
D. two years.
6. Insistently focusing on being depressed is
characteristic of
A. catastrophic thinking.
B. a ruminative coping style.
C. bipolar disorder.
D. learned helplessness.
7. The eating disorder that involves binge
eating followed by purging through selfinduced vomiting is
A. binge eating disorder.
B. bulimia nervosa.
C. anorexia nervosa.
D. compulsive eating disorder.
8. A dissociative disorder sometimes accompanied by unexpected sudden travel is
A. dissociate disorder.
B. dissociative personality disorder.
C. dissociative identity disorder.
D. dissociative amnesia.
9. _____ symptoms of schizophrenia reflect a
loss of normal functioning, while _______
symptoms reflect the addition of abnormal
functioning.
A. Cognitive; behavioral
B. Behavioral; cognitive
C. Positive; negative
D. Negative; positive
10. Antisocial personality disorder is characterized by _______, whereas borderline
personality disorder is characterized by
_______.
A. avoidance of impulsive behavior; avoidance of physical aggression
B. avoidance of physical aggression;
avoidance of impulsive behavior
C. a tendency to harm oneself; violence
toward others
D. violence toward others; a tendency to
harm oneself
Apply It!
11. What is the diathesis-stress model? In the
text this model was applied to schizophrenia. Apply it to one eating disorder and
one anxiety disorder.
Self- Tes t
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